Relationship between criminal legal system exposure and health care utilization in US adults with diabetes: A cross-sectional study

Background: Black Americans have a higher prevalence of diabetes compared to White Americans and have higher rates of complications and death. Exposure to the criminal legal system (CLS) is a social risk factor for chronic disease morbidity and mortality with significant overlap with populations most likely to experience poor diabetes outcomes. However, little is known about the association between CLS exposure and healthcare utilization patterns among U.S. adults with diabetes. Methods: Using data from the National Survey of Drug Use and Health (2015-2018) a cross-sectional, nationally representative sample of U.S. adults with diabetes was created. Negative binomial regression was used to test the association between lifetime CLS exposure and three utilization types (emergency department (ED), inpatient, and outpatient) controlling for relevant socio-demographic and clinical covariates. Results: Of 11,562 (weighted to represent 25,742,034 individuals) adults with diabetes, 17.1% reported lifetime CLS exposure. In unadjusted analyses, exposure was associated with increased ED (IRR 1.30 95% CI 1.17-1.46) and inpatient utilization (IRR 1.23, 95% CI 1.01-1.50), but not outpatient visits (IRR 0.99 95% CI 0.94-1.04). The association between CLS exposure and ED (IRR 1.02, p=0.70) and inpatient utilization (IRR 1.18, p=0.12) was attenuated in adjusted analyses. Low socioeconomic status, comorbid substance use disorder, and comorbid mental illness were independently associated with health care utilization in this population. Conclusions: Among those with diabetes, lifetime CLS exposure is associated with higher ED and inpatient visits in unadjusted analyses. Adjusting for socioeconomic status and clinical confounders attenuated these relationships, thus more research is needed to understand how CLS exposure interacts with poverty, structural racism, addiction and mental illness to influence health care utilization for adults with diabetes.