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Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study

Abstract

Aims/hypothesis

High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities.

Methods

Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40–59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension.

Results

Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity.

Conclusions/interpretation

In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people.

Graphical abstract

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Fig. 1

Abbreviations

CRS:

Civil Registration System

DMP:

Disease management programme

DNDR:

Danish National Diabetes Register

DNPR:

Danish National Prescription Registry

ISCED:

International Standard Classification of Education

RD:

Rate difference

References

  1. 1.

    Danish Health Authority (2008) Forløbsprogrammer for kronisk sygdom – generisk model og forløbsprogram for diabetes. Available from https://www.sst.dk/~/media/5C35B9DEA91B4E0A91458076F1994019.ashx. Accessed 4 Aug 2021

  2. 2.

    Rijken M, Hujala A, van Ginneken E, Melchiorre MG, Groenewegen P, Schellevis F (2018) Managing multimorbidity: profiles of integrated care approaches targeting people with multiple chronic conditions in Europe. Health Policy 122(1):44–52. https://doi.org/10.1016/j.healthpol.2017.10.002

  3. 3.

    Nolte E, Knai C, Saltman RB, European Observatory on Health Systems and Policies, World Health Organization, Seventh Framework Programme (European Commission) (2014) Assessing chronic disease management in European health systems: concepts and approaches. Available from http://www.ncbi.nlm.nih.gov/books/NBK458642/. Accessed 4 Aug 2021

  4. 4.

    Schiøtz ML, Stockmarr A, Høst D, Glümer C, Frølich A (2017) Social disparities in the prevalence of multimorbidity – a register-based population study. BMC Public Health 17(1):422. https://doi.org/10.1186/s12889-017-4314-8

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Møller SP, Laursen B, Johannesen CK, Tolstrup JS, Schramm S (2020) Patterns of multimorbidity and demographic profile of latent classes in a Danish population-a register-based study. PLoS One 15(8):e0237375. https://doi.org/10.1371/journal.pone.0237375

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Nowakowska M, Zghebi SS, Ashcroft DM et al (2019) The comorbidity burden of type 2 diabetes mellitus: patterns, clusters and predictions from a large English primary care cohort. BMC Med 17(1):145. https://doi.org/10.1186/s12916-019-1373-y

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Kristensen MAT, Guassora AD, Arreskov AB, Waldorff FB, Hølge-Hazelton B (2018) ‘I’ve put diabetes completely on the shelf till the mental stuff is in place’. How patients with doctor-assessed impaired self-care perceive disease, self-care, and support from general practitioners. A qualitative study. Scand J Prim Health Care 36(3):342–351. https://doi.org/10.1080/02813432.2018.1487436

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Frølich A, Ghith N, Schiøtz M, Jacobsen R, Stockmarr A (2019) Multimorbidity, healthcare utilization and socioeconomic status: a register-based study in Denmark. PLoS One 14(8):e0214183. https://doi.org/10.1371/journal.pone.0214183

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Walker RJ, Gebregziabher M, Martin-Harris B, Egede LE (2015) Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling. Patient Educ Couns 98(1):34–40. https://doi.org/10.1016/j.pec.2014.10.002

    Article  PubMed  Google Scholar 

  10. 10.

    Pedron S, Emmert-Fees K, Laxy M, Schwettmann L (2019) The impact of diabetes on labour market participation: a systematic review of results and methods. BMC Public Health 19(1):25. https://doi.org/10.1186/s12889-018-6324-6

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Sundstrup E, Jakobsen MD, Mortensen OS, Andersen LL (2017) Joint association of multimorbidity and work ability with risk of long-term sickness absence: a prospective cohort study with register follow-up. Scand J Work Environ Health 43(2):146–154. https://doi.org/10.5271/sjweh.3620

    Article  PubMed  Google Scholar 

  12. 12.

    Nexø MA, Pedersen J, Cleal B, Bjorner JB (2020) Increased risk of long-term sickness absence, lower rate of return to work and higher risk of disability pension among people with type 1 and type 2 diabetes mellitus: a Danish retrospective cohort study with up to 17 years’ follow-up. Diabet Med 37(11):1861–1865. https://doi.org/10.1111/dme.14203

    Article  PubMed  Google Scholar 

  13. 13.

    Kildemoes HW, Sørensen HT, Hallas J (2011) The Danish National Prescription Registry. Scand J Public Health 39(7 Suppl):38–41. https://doi.org/10.1177/1403494810394717

    Article  PubMed  Google Scholar 

  14. 14.

    Carstensen B, Kristensen JK, Marcussen MM, Borch-Johnsen K (2011) The National Diabetes Register. Scand J Public Health 39(7 Suppl):58–61. https://doi.org/10.1177/1403494811404278

    Article  PubMed  Google Scholar 

  15. 15.

    Jensen VM, Rasmussen AW (2011) Danish education registers. Scand J Public Health 39(7 Suppl):91–94. https://doi.org/10.1177/1403494810394715

    Article  PubMed  Google Scholar 

  16. 16.

    Carstensen B, Rønn PF, Jørgensen ME (2020) Prevalence, incidence and mortality of type 1 and type 2 diabetes in Denmark 1996–2016. BMJ Open Diabetes Res Care 8(1):e001071. https://doi.org/10.1136/bmjdrc-2019-001071

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Baadsgaard M, Quitzau J (2011) Danish registers on personal income and transfer payments. Scand J Public Health 39(7 Suppl):103–105. https://doi.org/10.1177/1403494811405098

    Article  PubMed  Google Scholar 

  18. 18.

    Pedersen CB (2011) The Danish Civil Registration System. Scand J Public Health 39(7 Suppl):22–25. https://doi.org/10.1177/1403494810387965

    Article  PubMed  Google Scholar 

  19. 19.

    Martinussen T, Vansteelandt S, Gerster M, von Bornemann Hjelmborg J (2011) Estimation of direct effects for survival data by using the Aalen additive hazards model. J R Stat Soc Ser B Stat Methodol 73(5):773–788

    Article  Google Scholar 

  20. 20.

    Rod NH, Lange T, Andersen I, Marott JL, Diderichsen F (2012) Additive interaction in survival analysis: use of the additive hazards model. Epidemiology 23(5):733–737. https://doi.org/10.1097/EDE.0b013e31825fa218

  21. 21.

    Leutz WN (1999) Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q 77(1):77–110. https://doi.org/10.1111/1468-0009.00125

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    European Commission (2017) Blocks: tools and methodologies to assess integrated care in Europe. Publications Office of the European Union, Luxembourg. https://doi.org/10.2875/69305

    Book  Google Scholar 

  23. 23.

    Hessler D, Bowyer V, Gold R, Shields-Zeeman L, Cottrell E, Gottlieb LM (2019) Bringing social context into diabetes care: intervening on social risks versus providing contextualized care. Curr Diab Rep 19(6):1–7. https://doi.org/10.1007/s11892-019-1149-y

    Article  Google Scholar 

  24. 24.

    Diabetes UK (2014) Improving the delivery of adult diabetes care through integration. Available from https://www.diabetes.org.uk/professionals/position-statements-reports/integrated-diabetes-care. Accessed 4 Aug 2021

  25. 25.

    Vrangbæk K (2020) Structuring complexity? – implementation of a disease management program for type II diabetes care in Denmark. Health Economics Policy and Law (in press)

  26. 26.

    Rudkjøbing A, Olejaz M, Birk HO, Nielsen AJ, Hernández-Quevedo C, Krasnik A (2012) Integrated care: a Danish perspective. BMJ 345:e4451. https://doi.org/10.1136/bmj.e4451

    Article  PubMed  Google Scholar 

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Authors’ relationships and activities

The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.

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Contributions

AMB conducted the analysis and was responsible for writing the manuscript. All authors were involved in the conception and design of the study. All authors discussed data analyses, critically revised the manuscript and approved the final version of the manuscript. AMB is responsible for the integrity of the work as a whole.

Corresponding author

Correspondence to Anne Mette Bender.

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Bender, A.M., Vrangbæk, K., Lange, T. et al. Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study. Diabetologia (2021). https://doi.org/10.1007/s00125-021-05559-4

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Keywords

  • Comorbidity
  • Disability pension
  • Inequality
  • Integrated care
  • Interaction
  • Socioeconomic position
  • Type 2 diabetes mellitus