Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders.

IMPORTANCE Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote longterm medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about howhealth care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management. OBJECTIVE To analyze how preexistingMH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017. EXPOSURES Patients were assigned to groups on the basis of a 2-year look-back period forMH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or noMH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabeteswas diagnosed. MAIN OUTCOMES AND MEASURES Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores. RESULTS Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexistingMH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, -0.09; 95% CI, -0.13 to -0.04; P <.001) or bothMHand SU disorders (decrease in DCSI score, -0.13; 95% CI, -0.16 to -0.09; P <.001), but notMHdisorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, -0.41 [95% CI, -0.43 to -0.39] for 1-2 visits, -0.50 [95% CI, -0.52 to -0.48] for 3-4 visits, -0.39 [95% CI, -0.41 to -0.37] for 5-8 visits, and -0.15 [95% CI, -0.17 to -0.12] for >= 9 visits; P < .001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P < .001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P = .004; or both MH and SU disorders, 0.008 [95% CI, 0.0060.011], P < .001), compared with patients without MH or SU disorders. CONCLUSIONS AND RELEVANCE Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.