Use of diabetes preventive care and complications risk in two African-American communities

Disparities in preventative diabetic foot examination

The objective of this study was to assess the overall differences in the standard of preventive foot care for patients at risk of diabetic foot ulceration and to identify specific demographic factors affecting these health care practices, including race and ethnicity. The National Health and Nutrition Examination Survey data for 2011 to 2018 were analyzed. Participants (20 years and older) with diabetes were categorized as White, Black, Hispanic, Asian, and others (including multiracial participants) based on self-reported race and ethnicity. The primary outcome was foot examination over the past year administered by a medical professional. Logistic regression was performed to examine the effects of race and ethnicity on the annual diabetic foot examination, controlling for age (65 years and older), gender, and health insurance status. Among the 2,836 participants included in the study (weighted percentage: 61.1% were White, 13.9% were Black, 15.1% were Hispanic, 5.4% were Asian, and 4.5% were other), 2,018 (weighted percentage: 71.6%) received annual diabetic foot examination over the past year. Hispanic participants (adjusted odds ratio [aOR] = 0.685; 95% CI, 0.52-0.90) were significantly less likely than White participants to receive an annual foot examination (Black participants: aOR = 1.11; 95% CI, 0.83-1.49; Asian participants: aOR = 0.80; 95% CI, 0.60-1.07; other participants: aOR = 0.66; 95% CI, 0.40-1.10). Factors associated with receipt of foot examination were age 65 years or older (aOR = 1.42; 95% CI, 1.05-1.92) and having health insurance (aOR = 3.02; 95% CI, 2.27-4.03). Our findings suggest that Hispanic adults with diabetes are receiving disproportionately lower rates of preventive foot care compared with their White counterparts. This significant variation in the standard of care for individuals with diabetes reflects the need to further identify factors driving the disparities in preventive foot care services among racial and ethnic minority groups.

Are racial/ethnic minorities recently diagnosed with diabetes less likely than white individuals to receive guideline-directed diabetes preventive care?

BACKGROUND

Diabetes mellitus has reached epidemic proportions in the United States. As the prevalence of diabetes continues to rise, the burden of disease is divided unevenly among different populations. Racial/ethnic disparities in diabetes care are pervasive, including the provision of care for prevention of complications. Prevention efforts should be focused on the time that immediately follows a diagnosis of diabetes. The aim of this study was to assess racial/ethnic differences in the receipt of guideline-directed diabetes care for complication prevention by individuals recently diagnosed with diabetes.

METHODS

We used repeated cross-sections of individuals recently diagnosed with diabetes (within the past 5 years) from the National Health Interview Survey from 2011 to 2017. Multivariate regression was used to estimate the associations between race/ethnicity (non-Hispanic White, non-Hispanic Black and Hispanic) and guideline-directed process measures for prevention of diabetes complications (visits to an eye and foot specialist, and blood pressure and cholesterol checks by a health professional - each in the prior year). We assessed effect modification of these associations by socioeconomic status (SES).

RESULTS

In a sample of 7,341 participants, Hispanics had lower rates of having any insurance coverage (75.9 %) than Non-Hispanic Whites (93.2 %) and Blacks (88.1 %; p<0.001). After adjustment for demographics, total comorbidities, SES, and health insurance status, Hispanics were less likely to have an eye exam in the prior year (OR 0.80; (95 % CI 0.65-0.99); p=0.04) and a blood pressure check (OR 0.42; (95 % CI 0.28-0.65); p<0.001) compared to Non-Hispanic Whites. There was no significant effect modification of race/ethnicity by SES.

CONCLUSIONS

Hispanics recently diagnosed with diabetes were less likely to receive some indicators of guideline-directed care for the prevention of complications. Lack of insurance and SES may partially explain those differences. Future work should consider policy change and providers' behaviors linked to racial/ethnic disparities in diabetes care.

Predicting Type 2 Diabetes Using Logistic Regression and Machine Learning Approaches

Diabetes mellitus is one of the most common human diseases worldwide and may cause several health-related complications. It is responsible for considerable morbidity, mortality, and economic loss. A timely diagnosis and prediction of this disease could provide patients with an opportunity to take the appropriate preventive and treatment strategies. To improve the understanding of risk factors, we predict type 2 diabetes for Pima Indian women utilizing a logistic regression model and decision tree—a machine learning algorithm. Our analysis finds five main predictors of type 2 diabetes: glucose, pregnancy, body mass index (BMI), diabetes pedigree function, and age. We further explore a classification tree to complement and validate our analysis. The six-fold classification tree indicates glucose, BMI, and age are important factors, while the ten-node tree implies glucose, BMI, pregnancy, diabetes pedigree function, and age as the significant predictors. Our preferred specification yields a prediction accuracy of 78.26% and a cross-validation error rate of 21.74%. We argue that our model can be applied to make a reasonable prediction of type 2 diabetes, and could potentially be used to complement existing preventive measures to curb the incidence of diabetes and reduce associated costs.

Type 2 Diabetes Mellitus Screening and Risk Factors Using Decision Tree: Results of Data Mining

Objectives:

The aim of this study was to examine a predictive model using features related to the diabetes type 2 risk factors.

Methods:

The data were obtained from a database in a diabetes control system in Tabriz, Iran. The data included all people referred for diabetes screening between 2009 and 2011. The features considered as “Inputs” were: age, sex, systolic and diastolic blood pressure, family history of diabetes, and body mass index (BMI). Moreover, we used diagnosis as “Class”. We applied the “Decision Tree” technique and “J48” algorithm in the WEKA (3.6.10 version) software to develop the model.

Results:

After data preprocessing and preparation, we used 22,398 records for data mining. The model precision to identify patients was 0.717. The age factor was placed in the root node of the tree as a result of higher information gain. The ROC curve indicates the model function in identification of patients and those individuals who are healthy. The curve indicates high capability of the model, especially in identification of the healthy persons.

Conclusions:

We developed a model using the decision tree for screening T2DM which did not require laboratory tests for T2DM diagnosis.

Diabetes eye screening in urban settings serving minority populations: detection of diabetic retinopathy and other ocular findings using telemedicine

IMPORTANCE

The use of a nonmydriatic camera for retinal imaging combined with the remote evaluation of images at a telemedicine reading center has been advanced as a strategy for diabetic retinopathy (DR) screening, particularly among patients with diabetes mellitus from ethnic/racial minority populations with low utilization of eye care.

OBJECTIVE

To examine the rate and types of DR identified through a telemedicine screening program using a nonmydriatic camera, as well as the rate of other ocular findings.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study (Innovative Network for Sight [INSIGHT]) was conducted at 4 urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority and uninsured persons with diabetes. Participants included persons aged 18 years or older who had type 1 or 2 diabetes mellitus and presented to the community-based settings.

MAIN OUTCOMES AND MEASURES

The percentage of DR detection, including type of DR, and the percentage of detection of other ocular findings.

RESULTS

A total of 1894 persons participated in the INSIGHT screening program across sites, with 21.7% having DR in at least 1 eye. The most common type of DR was background DR, which was present in 94.1% of all participants with DR. Almost half (44.2%) of the sample screened had ocular findings other than DR; 30.7% of the other ocular findings were cataract.

CONCLUSIONS AND RELEVANCE

In a DR telemedicine screening program in urban clinic or pharmacy settings in the United States serving predominantly ethnic/racial minority populations, DR was identified on screening in approximately 1 in 5 persons with diabetes. The vast majority of DR was background, indicating high public health potential for intervention in the earliest phases of DR when treatment can prevent vision loss. Other ocular conditions were detected at a high rate, a collateral benefit of DR screening programs that may be underappreciated.

Race/ethnic difference in diabetes and diabetic complications

Health disparities in diabetes and its complications and comorbidities exist globally. A recent Endocrine Society Scientific Statement described the Health Disparities in several endocrine disorders, including type 2 diabetes. In this review, we summarize that statement and provide novel updates on race/ethnic differences in children and adults with type 1 diabetes, children with type 2 diabetes, and in Latino subpopulations. We also review race/ethnic differences in the epidemiology of diabetes, prediabetes, and diabetes complications and mortality in the United States and globally. Finally, we discuss biological, behavioral, social, environmental, and health system contributors to diabetes disparities to identify areas for future preventive interventions.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Electronic health records vs Medicaid claims: completeness of diabetes preventive care data in community health centers

PURPOSE

Electronic Health Record (EHR) databases in community health centers (CHCs) present new opportunities for quality improvement, comparative effectiveness, and health policy research. We aimed (1) to create individual-level linkages between EHR data from a network of CHCs and Medicaid claims from 2005 through 2007; (2) to examine congruence between these data sources; and (3) to identify sociodemographic characteristics associated with documentation of services in one data set vs the other.

METHODS

We studied receipt of preventive services among established diabetic patients in 50 Oregon CHCs who had ever been enrolled in Medicaid (N = 2,103). We determined which services were documented in EHR data vs in Medicaid claims data, and we described the sociodemographic characteristics associated with these documentation patterns.

RESULTS

In 2007, the following services were documented in Medicaid claims but not the EHR: 11.6% of total cholesterol screenings received, 7.0% of total influenza vaccinations, 10.5% of nephropathy screenings, and 8.8% of tests for glycated hemoglobin (HbA(1c)). In contrast, the following services were documented in the EHR but not in Medicaid claims: 49.3% of cholesterol screenings, 50.4% of influenza vaccinations, 50.1% of nephropathy screenings, and 48.4% of HbA(1c) tests. Patients who were older, male, Spanish-speaking, above the federal poverty level, or who had discontinuous insurance were more likely to have services documented in the EHR but not in the Medicaid claims data.

CONCLUSIONS

Networked EHRs provide new opportunities for obtaining more comprehensive data regarding health services received, especially among populations who are discontinuously insured. Relying solely on Medicaid claims data is likely to substantially underestimate the quality of care.

Clustering of unhealthy lifestyle behaviors is associated with nonadherence to clinical preventive recommendations among adults with diabetes

AIM

Analyze clustering of unhealthy lifestyle behavior and its relationship with nonadherence to clinical preventive care services among Spanish diabetic adults.

METHODS

Cross-sectional study including 2156 diabetic adults from the 2006 Spanish National Health Survey. Subjects were asked about their uptake of BP measurement, lipid profile, influenza vaccination, and dental examination. Lifestyle behaviors included smoking status, physical activity, alcohol consumption, and dieting. Binary logistic regression models were built to assess the association between clustering of unhealthy lifestyle and the uptake of each preventive activity.

RESULTS

Almost 16% and 36% of the subjects had not undergone blood pressure (BP) and blood lipids measurements, respectively. Forty percent had not been vaccinated and 72% had not received dental examination. Fourteen percent of the subjects had three to four unhealthy behaviors and this increased the probability of not having BP check-up (OR 2.32, 95% CI 1.38-3.91), blood lipids testing (OR 1.63, 95% CI 1.14-2.33), and not being vaccinated (OR 1.99, 95% CI 1.37-2.89). Number of unhealthy lifestyle behaviors is linearly associated with number of preventive measures unfulfilled.

CONCLUSIONS

Adherence to recommended clinical preventive services is under desirable levels among Spanish diabetes sufferers. These preventive services are provided neither equitably nor efficiently, since subjects with unhealthier lifestyles are less likely to receive them.

A survey of oral health education provided by certified diabetes educators

The purpose of this study was to investigate certified diabetes educators' (CDEs) perceptions of the adequacy of their diabetes education curricula in providing oral health information. A questionnaire was mailed to all CDEs with a mailing address in South Carolina (SC), United States (US). Of the 130 respondents, between 50%-60% indicated that they adequately addressed frequent dental visits, daily brushing and flossing, and importance of good oral hygiene. Almost all (93.8%) reported that their curricula did not include an oral health module; the two predominant reasons were: not having enough time (61.0%), and not knowing enough about oral health and its relationship to diabetes (37.0%). Respondents who expressed that they did not know enough about oral health and its relationship to diabetes were less likely to provide adequate 'oral-health-related information' (p=0.008), especially information about the effect of periodontal disease on diabetes (p=0.016). This study indicates that SC CDEs do not routinely provide comprehensive oral health education to people with diabetes primarily due to lack of time and knowledge related to oral health. To better serve their patients, CDEs should integrate oral health education in the diabetes education curriculum.

The role of culture in health literacy and chronic disease screening and management

Cultural and language differences and socioeconomic status interact with and contribute to low health literacy, defined as the inability to understand or act on medical/therapeutic instructions. Health literacy is increasingly recognized as an important factor in patient compliance, cancer screening utilization, and chronic disease outcomes. Commendable efforts have been initiated by the American Medical Association and other organizations to address low health literacy among patients. Less work has been done, however, to place health literacy in the broader context of socioeconomic and cultural differences among patients and providers that hinder communication and compliance. This review examines cultural influences on health literacy, cancer screening and chronic disease outcomes. We argue that cultural beliefs around health and illness contribute to an individual's ability to understand and act on a health care provider's instructions. This paper proposes key aspects of the intersection between health literacy and culturally varying beliefs about health which merit further exploration.

Characteristics of insured patients with persistent gaps in diabetes care services: the Translating Research into Action for Diabetes (TRIAD) study

BACKGROUND

Although preventing diabetes complications requires long-term management, little is known about which patients persistently fail to get recommended care.

OBJECTIVE

To determine the frequency and correlates of persistent, long-term gaps in diabetes care.

METHOD

: The study population included 8392 patients with diabetes. Patient surveys and medical records from 10 health plans over 3 years provided data on socioeconomic characteristics, access to care, social support, and mental and physical health, and diabetes preventive care services. We defined a "persistent gap" as a participant's missing a preventive care service for the entire 3 years. Services considered included hemoglobin A1c, cholesterol, and albuminuria tests, and foot and dilated eye examinations.

RESULTS

Thirty percent of participants had at least 1 persistent gap. The most common gaps were lipid testing (11.6%), microalbuminuria testing (9.7%), and eye examinations (9.0%). Persistent gaps were 18% to 42% higher for young patients, lean persons, those with low income, employed persons, smokers, those with diabetes less than 5 years, and patients with none or 1 comorbid conditions. Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with gaps in care.

CONCLUSIONS

Persistent gaps in diabetes care are common even among insured patients. Patients with lower income, younger age, fewer years of diabetes, having fewer comorbidities, taking fewer medications, and poor health behaviors are vulnerable to persistent gaps in care and a group who warrant targeted interventions to improve preventive diabetes care.

Insurance continuity and receipt of diabetes preventive care in a network of federally qualified health centers

BACKGROUND AND OBJECTIVES

Having health insurance is usually associated with better access to care and better health outcomes. For patients receiving care at Federally Qualified Health Centers (FQHCs), where care is provided regardless of insurance status, the role health insurance status plays in affecting receipt of services is less well understood.

RESEARCH DESIGN

We used practice management data from a coalition of FQHCs in Oregon, and linked to Oregon's electronic insurance data, to examine whether receipt of diabetes preventive care services was associated with continuity of insurance coverage among adult FQHC patients receiving diabetes care in 2005.

RESULTS

About one-third (32%) of patients with diabetes received a flu vaccination in 2005, 36% an LDL screening, 54% at least 1 HbA1c screening, and 21% a nephropathy screening. Compared with the continuously insured, the continuously uninsured were less likely to receive an LDL screening, a flu vaccination, and/or a nephropathy screening; those with partial coverage were less likely than the continuously insured to receive a flu shot, at least 1 HbA1c screening, or an LDL screening.

CONCLUSIONS

Our results suggest that FQHCs do an excellent job in delivering most services to their uninsured and partially insured patients, but also underscore that for diabetic patients from underserved communities, having both an FQHC medical home and continuous health insurance plays a critical role in receiving optimal chronic disease management. Our study is one of the first to demonstrate how electronic administrative data from a network of FQHCs can be successfully used to gauge the state of healthcare delivery.

Self-care and professionally guided care in osteoarthritis: racial differences in a population-based sample

OBJECTIVE

The aim of this study was to examine the prevalence of self-management practices among older White and African American persons with osteoarthritis. Self-management was defined broadly to include all behaviors adopted to reduce morbidity, whether recommended by physicians or not.

METHODS

A population-based sample of Medicare beneficiaries (N = 551) was recruited. An expanded set of self-management behaviors using structured and open-ended inquiry, along with use of arthritis-specific medications was elicited.

RESULTS

Few differences in self-care behaviors between race groups were found. However, older African American persons were significantly less likely to have prescriptions for nonsteroidal anti-inflammatory agents (NSAIDs) and more likely to use over-the-counter nonprescription analgesics.

DISCUSSION

Older White and African American persons made similar use of self-care strategies to reduce disease morbidity. African Americans without access to prescription pain relievers substituted nonprescription analgesics. A broader view of self-management is valuable for assessing the ways people may move between professionally guided care and self-care.

Family history of diabetes, awareness of risk factors, and health behaviors among African Americans

OBJECTIVES

We examined the role of family history of diabetes in awareness of diabetes risk factors and engaging in health behaviors.

METHODS

We conducted a cross-sectional analysis of 1122 African American adults without diabetes who were participants in Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together).

RESULTS

After adjustment for age, gender, income, education, body mass index, and perceived health status, African Americans with a family history of diabetes were more aware than those without such a history of several diabetes risk factors: having a family member with the disease (relative risk [RR]=1.09; 95% confidence interval [CI]=1.03, 1.15), being overweight (RR=1.12; 95% CI=1.05, 1.18), not exercising (RR=1.17; 95% CI=1.07, 1.27), and consuming energy-dense foods (RR=1.10; 95% CI=1.00, 1.17). Also, they were more likely to consume 5 or more servings of fruits and vegetables per day (RR=1.31; 95% CI=1.02, 1.66) and to have been screened for diabetes (RR=1.21; 95% CI=1.12, 1.29).

CONCLUSIONS

African Americans with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviors than were African Americans without a family history of the disease.

Racial/Ethnic and social class differences in preventive care practices among persons with diabetes

BACKGROUND

Diabetes is the sixth leading cause of death in the United States. Persons with diabetes are at increased risk for serious complications including CVD, stroke, retinopathy, amputation, and nephropathy. Minorities have the highest incidence and prevalence of diabetes and related complications compared to other racial groups. Preventive care practices such as smoking cessation, eye examinations, feet examinations, and yearly checkups can prevent or delay the incidence and progression of diabetes related complications. The purpose of this study was to examine racial/ethnic differences in diabetes preventive care practices by several socio-demographic characteristics including social class.

METHODS

Data from the Behavioral Risk Factor Surveillance Survey for 1998-2001 were used for analyses. The study population consisted of persons who indicated having diabetes on the BRFSS, 35 yrs and older, and Non-Hispanic Black, non-Hispanic White, or Hispanic persons. Logistic regression was used in analyses.

RESULTS

Contrary to our hypotheses, Blacks and Hispanics engaged in preventive care more frequently than Whites. Whites were less likely to have seen a doctor in the previous year, less likely to have had a foot exam, more likely to smoke, and less likely to have attempted smoking cessation. Persons of lower social class were at greatest risk for not receiving preventive care regardless of race/ethnicity. Persons with no health care coverage were twice as likely to have not visited the doctor in the previous year and twice as likely to have not had an eye exam, 1.5 times more likely to have not had a foot exam or attempted smoking cessation.

CONCLUSION

This study showed that persons of lower social class and persons with no health insurance are at greatest risk for not receiving preventive services.

Influences on screening for chronic diabetes complications in type 1 diabetes

Screening for the long-term complications of diabetes is a critical component of diabetes management; however, evidence demonstrates that screening rates in diabetes populations are suboptimal. Our objective was to determine the use and predictors of optimal screening behavior, defined as receiving a fasting lipid test, dilated eye exam, spot urine test, foot examination, blood pressure reading, and hemoglobin A1c (HbA1c) in the previous year in a representative cohort of subjects with type 1 diabetes. Data are from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective cohort study of subjects with childhood onset type 1 diabetes. Data from 325 participants who responded to a survey during 1999-2001 were included in analyses. Reported screening rates were as follows: 87.9% had at least one HbA1c measurement in the past year, 63% had a foot exam, 73.3% had a spot urine test, 81.9% had a dilated eye exam, 93.5% had a blood pressure reading and 68.7% received a fasting lipid profile. Within this group, 37.7% of subjects reported undergoing all five tests (optimal screening). Independent correlates of optimal screening were receiving care from a specialist provider (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.4-4.1) and blood glucose monitoring at least weekly (OR = 2.6; 95% CI: 1.1-6.2). These findings indicate that a large proportion of persons with type 1 diabetes are not being screened at the optimal level. Our data indicate that efforts to rectify this should focus on men and those who do not monitor blood glucose, and should involve primary care practitioners.

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings.

RESEARCH DESIGN AND METHODS

We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control).

RESULTS

Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP.

CONCLUSIONS

In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

Race differences in long-term diabetes management in an HMO

OBJECTIVE

We examined race differences in diabetes outcomes over 4-8 years in a single HMO.

RESEARCH DESIGN AND METHODS

We identified black and white adult diabetic patients who were continuously enrolled (1992-2001) and in whom diabetes was 1) diagnosed before 1994 (n = 1,686) or 2) newly diagnosed in 1994-1997 (n = 1,280). We used hierarchical models to estimate the effect of race on average annual HbA(1c) (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race.

RESULTS

At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI -0.12 to 0.34) in black than in white men but was 0.30 higher (0.14-0.46; P = 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17-0.80; P = 0.007) and was 0.05 among women (-0.20 to -0.31), which was positive but not significant.

CONCLUSIONS

Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management.

Ethnic Disparities: Control of Glycemia, Blood Pressure, and LDL Cholesterol Among US Adults with Type 2 Diabetes

OBJECTIVE:

To examine ethnic disparities in the quality of diabetes care among adults with diabetes in the US through a systematic qualitative review.

DATA SOURCES:

Material published in the English language was searched from 1993 through June 2003 using PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center.

STUDY SELECTION AND DATA EXTRACTION:

Studies of patients with diabetes in which at least 50% of study participants were ethnic minorities and studies that made ethnic group comparisons were eligible. Research on individuals having prediabetes, those <18 years of age, or women with gestational diabetes were excluded. Reviewers used a reproducible search strategy. A standardized abstraction and grading of articles for publication source and content were used. Data on glycemia, blood pressure, and low-density lipoprotein cholesterol (LDL-C) were extracted in patients with diabetes. A total of 390 studies were reviewed, with 78 meeting inclusion criteria.

DATA SYNTHESIS:

Ethnic minorities had poorer outcomes of care than non-Hispanic whites. These disparities were most pronounced for glycemic control and least evident for LDL-C control. Most studies showed blood pressure to be poorly controlled among ethnic minorities.

CONCLUSIONS:

Control of risk factors for diabetes (glycemia, blood pressure, LDL-C) is challenging and requires routine assessment. These findings indicate that additional efforts are needed to promote diabetes quality of care among minority populations.

Management of chronic disease by patients

Chronic conditions dominate health care in most parts of the world, including the United States. Management of a disease by the patient is central to control of its effects. A wide range of influences in the person's social and physical environments enhance or impede management efforts. Interventions to improve management by patients can produce positive outcomes including better monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health care use. Successful programs have been theory based. Self-regulation is a promising framework for the development of interventions. Nonetheless, serious gaps in understanding and improving disease management by patients remain because of an emphasis on clinical settings for program delivery, neglect of the factors beyond patient behavior that enable or deter effective management, limitations of study designs in much work to date, reliance on short-term rather than long-term assessments, and failure to evaluate the independent contribution of various program components.

Trends in the prevalence of diabetic nephropathy in type 1 and type 2 diabetes

PURPOSE OF REVIEW

To summarize recent trends in the prevalence of nephropathy due to diabetes and to assess the causes of these changes. Such analysis may influence our strategy to reduce the increasing numbers of cases.

RECENT FINDINGS

Registry data show a progressive increase in the number of cases of nephropathy due to type 2 diabetes such that diabetes is now the leading cause of end-stage renal failure. Despite the increasing incidence of type 1 diabetes, European data indicate the numbers of type 1 patients going on to dialysis are stable. The increase in the prevalence of type 2 diabetes, which in itself is related to increasing levels of obesity, is a major factor but the increase in end-stage renal failure is disproportionately greater. Other factors are therefore important such as earlier development of diabetes and better prevention of coronary events. Similar changes are occurring worldwide. Clinical predictors and genetic markers are being studied.

SUMMARY

More active management of proteinuric type 2 diabetic patients is required to achieve the demanding targets recommended on the basis of clinical trial data. However, the figures suggest that only widespread application of public health measures aimed at the epidemic of type 2 diabetes itself will prevent further rapid escalation of the numbers of type 2 patients reaching end-stage renal failure.