Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature

Childhood cognition and risk factors for cardiovascular disease in midadulthood: the 1958 British Birth Cohort Study

OBJECTIVES

We sought to establish whether associations between childhood cognition and risk factors for cardiovascular disease in adulthood are explained by common causes, or adult social position or health behavior.

METHODS

We analyzed associations between cognition at age 11 and cardiovascular disease risk factors at age 45 in the 1958 British birth cohort (n=9377), with and without adjustment for covariates.

RESULTS

General ability was inversely associated with systolic and diastolic blood pressure, glycosylated hemoglobin, triglycerides (in women), body mass index, and waist circumference. Systolic blood pressure decreased by 0.47 mm Hg (95% confidence interval [CI]=-0.90, -0.05) for a 1-standard-deviation increase in ability. Separate adjustment for social class at birth, education level by adulthood, adult social class, and health behaviors reduced the associations respectively by 14% to 34%, 36% to 50%, 14% to 36%, and 24% to 73%. Full adjustment reduced associations between ability and risk factors at age 45 years by 43% to 92%, abolishing all associations.

CONCLUSIONS

Increments across the distribution of childhood cognition are associated with improvements in cardiovascular risk profile in midlife, with associations primarily mediated through adult health behavior and social destinations.

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.

Individual-level socioeconomic status is associated with worse asthma morbidity in patients with asthma

BACKGROUND

Low socioeconomic status (SES) has been linked to higher morbidity in patients with chronic diseases, but may be particularly relevant to asthma, as asthmatics of lower SES may have higher exposures to indoor (e.g., cockroaches, tobacco smoke) and outdoor (e.g., urban pollution) allergens, thus increasing risk for exacerbations.

METHODS

This study assessed associations between adult SES (measured according to educational level) and asthma morbidity, including asthma control; asthma-related emergency health service use; asthma self-efficacy, and asthma-related quality of life, in a Canadian cohort of 781 adult asthmatics. All patients underwent a sociodemographic and medical history interview and pulmonary function testing on the day of their asthma clinic visit, and completed a battery of questionnaires (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire, and Asthma Self-Efficacy Scale). General Linear Models assessed associations between SES and each morbidity measure.

RESULTS

Lower SES was associated with worse asthma control (F = 11.63, p < .001), greater emergency health service use (F = 5.09, p = .024), and worse asthma self-efficacy (F = 12.04, p < .01), independent of covariates. Logistic regression analyses revealed that patients with <12 years of education were 55% more likely to report an asthma-related emergency health service visit in the last year (OR = 1.55, 95%CI = 1.05-2.27). Lower SES was not related to worse asthma-related quality of life.

CONCLUSIONS

Results suggest that lower SES (measured according to education level), is associated with several indices of worse asthma morbidity, particularly worse asthma control, in adult asthmatics independent of disease severity. Results are consistent with previous studies linking lower SES to worse asthma in children, and add asthma to the list of chronic diseases affected by individual-level SES.

The effects of a nurse case manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial

BACKGROUND

Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care.

METHODS

We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data.

RESULTS

At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], -14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, -31.0; adjusted RR, 0.66; 95% CI, 0.43-1.00; rate reduction downward arrow 34%).

CONCLUSION

These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00022750.

Determinants of quality in diabetes care process: The population-based Torino Study

OBJECTIVE

To investigate the role of clinical and socioeconomic variables as determinants of adherence to recommended diabetes care guidelines and assess differences in the process of care between diabetologists and general practitioners.

RESEARCH DESIGN AND METHODS

We identified diabetic residents in Torino, Italy, as of 31 July 2003, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations registered during the subsequent 12 months and performed regression analyses to identify associations with quality-of-care indicators based on existing guidelines.

RESULTS

After 1 year, only 35.8% of patients had undergone a comprehensive assessment. In the multivariate models, factors independently and significantly associated with lower quality of care were age >or=75 years (prevalence rate ratio [PRR] 0.66 [95% CI 0.61-0.70]) and established cardiovascular disease (0.89 [0.86-0.93]). Disease severity (PRR for insulin-treated patients 1.45 [1.38-1.53]) and diabetologist consultation (PRR 3.34 [3.17-3.53]) were positively associated with high quality of care. No clear association emerged between sex and socioeconomic status. These differences were strongly reduced in patients receiving diabetologist care compared with patients receiving general practitioner care only.

CONCLUSIONS

Despite widespread availability of guidelines and simple screening procedures, a nonnegligible portion of the diabetic population, namely elderly individuals and patients with less severe forms of the disease, are not properly cared for. As practitioners in diabetes centers are more likely to adhere to guidelines than general practitioners, quality in the diabetes care process can be improved by increasing the intensity of disease management programs, with greater participation by general practitioners.

Gender differences in the socioeconomic gradient in self-reported diabetes: does health service access play a role?

AIMS

To investigate the hypothesis that gender difference in the socioeconomic gradient of self-reported diabetes might be partially determined by a detection bias: among low SEP men, but not women, a less frequent use of medical care would result in lower diabetes detection and awareness.

METHODS

We conducted a cross-sectional analysis of 2387 (57.1% women) Brazilian university non-faculty civil servants. We quantified the association between educational attainment (a marker of socioeconomic position) and self-reported diabetes through gender-specific logistic regression models adjusting for age. Health insurance coverage (a marker of potential health care access) and never having had serum cholesterol tested (a marker of actual care access) were analyzed to investigate the role of detection bias.

RESULTS

Compared to participants with college education or higher, the adjusted odds ratio (OR) and 95% confidence interval for diabetes for those with less than high school was 2.5 (1.0-6.5) in men and 5.0 (2.1-11.7) in women. Only among men we observed an increment in this OR after an additional adjustment for markers of care access [men 3.5 (1.3-9.1); women 4.9 (1.9-12.1)].

CONCLUSIONS

Our findings suggest that health service access may explain some of the gender difference in the socioeconomic gradient of self-reported diabetes.

The polarizing effect of news media messages about the social determinants of health

Framing health problems in terms of the social determinants of health aims to shift policy attention to nonmedical strategies to improve population health, yet little is known about how the public responds to these messages. We conducted an experiment to test the effect of a news article describing the social determinants of type 2 diabetes on the public's support for diabetes prevention strategies. We found that exposure to the social determinants message led to a divergence between Republicans' and Democrats' opinions, relative to their opinions after viewing an article with no message about the causes of diabetes. These results signify that increasing public awareness of the social determinants of health may not uniformly increase public support for policy action.

Addressing the need to tailor treatment to the spectrum of type 2 diabetes: new perspectives

Type 2 diabetes mellitus is characterized by the progressive loss of beta cell function, which occurs after many years of insulin resistance. Within this definition, clinicians may see a diverse array of presentations, suggesting different proportions of these two pathogenic factors and a complex etiology. There are also differences in the rate of type 2 diabetes progression in each patient, so treatments must be reviewed frequently to respond to changing severity of pathophysiologies. This article first considers some of the heritable factors and the pathogenic heterogeneity of type 2 diabetes. Relevant socioeconomic and demographic factors influencing disease development are reviewed after that, while emphasizing how a patient's treatment requires changes over time.

Socio-economic differences in the prevalence of diabetes in Italy: the population-based Turin study

BACKGROUND AND AIMS

A surveillance programme on diabetes based on administrative data is being implemented in the city of Turin, Italy. The aim of this study is to assess socio-economic differences in the prevalence of diabetes in this large Italian population-based cohort.

METHODS AND RESULTS

People with known diabetes resident in Turin on July 31, 2003 were identified through three data sources: the regional register of persons with diabetes, hospital discharges and prescriptions for antidiabetic drugs. Data sources were linked to the Turin population register to obtain individual data on educational level and census tract median income. Missing cases were estimated by using the capture-recapture method. We identified 34,420 persons with diabetes; prevalence adjusted for undercount was 4.91% (95% Confidence Intervals: 4.69-5.22) among men and 4.68% (4.41-5.08) among women. Age adjusted prevalence ratios between low and high educational levels were 2.32 (2.23-2.41) in men, and 3.45 (3.28-3.62) in women. Social inequalities were larger in women than in men and in people aged 21-65 years than in those age >65 years.

CONCLUSION

This population-based study shows that there are socio-economic inequalities in the prevalence of the disease, particularly in women, and in young people. Our findings indicate that: (1) prevention of diabetes should be mainly focused on the socially disadvantaged strata of the population; (2) a low cost surveillance programme of diabetes using routinely collected data is feasible to better assist public health policies.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

AIMS/HYPOTHESIS

The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.

METHODS

We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.

RESULTS

In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4).

CONCLUSIONS/INTERPRETATION

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Ethnic disparities in blood pressure management in patients with hypertension after the introduction of pay for performance

PURPOSE

Little is known about the impact of pay-for-performance incentives on health care disparities. We examined ethnic disparities in the management of hypertension among patients with and without cardiovascular comorbidities after the implementation of a major pay-for-performance incentive scheme in UK primary care.

METHODS

We undertook a population-based, cross-sectional survey of medication prescriptions and blood pressure control among patients with hypertension using electronic medical records from 16 family practices in southwest London.

RESULTS

Black patients with hypertension were significantly less likely to achieve an established treatment target for blood pressure control than white or South Asian patients (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-0.99). The prevalence of cardiovascular comorbidities was higher among South Asian patients with hypertension than among their white or black counterparts (41.3% vs 28.5% vs 28.8%). The presence of 2 or more cardiovascular comorbidities was associated with significantly improved blood pressure control among white patients but not among black or South Asian patients (mean systolic blood pressure, -9.4 mm Hg, -0.6 mm Hg, and -1.8 mm Hg, respectively). South Asian patients with poorly controlled hypertension were prescribed fewer antihypertensive medications than their black or white peers (adjusted odds ratio, 0.66; 95% confidence interval, 0.46-0.96).

CONCLUSIONS

Ethnic disparities in the management of hypertension have persisted in the United Kingdom despite major investment in quality improvement initiatives, including pay for performance. These disparities are particularly marked among patients with multiple cardiovascular conditions.

Socioeconomic status and improvements in lifestyle, coronary risk factors, and quality of life: the Multisite Cardiac Lifestyle Intervention Program

OBJECTIVES

We sought to clarify whether patients of low socioeconomic status (SES) can make lifestyle changes and show improved outcomes in coronary heart disease (CHD), similar to patients with higher SES.

METHODS

We examined lifestyle, risk factors, and quality of life over 3 months, by SES and gender, in 869 predominantly White, nonsmoking CHD patients (34% female) in the insurance-sponsored Multisite Cardiac Lifestyle Intervention Program. SES was defined primarily by education.

RESULTS

At baseline, less-educated participants were more likely to be disadvantaged (e.g., past smoking, sedentary lifestyle, high fat diet, overweight, depression) than were higher-SES participants. By 3 months, participants at all SES levels reported consuming 10% or less dietary fat, exercising 3.5 hours per week or more, and practicing stress management 5.5 hours per week or more. These self-reports were substantiated by improvements in risk factors (e.g., 5-kg weight loss, and improved blood pressure, low-density lipoprotein cholesterol, and exercise capacity; P < .001), and accompanied by improvements in well-being (e.g., depression, hostility, quality of life; P < .001).

CONCLUSIONS

The observed benefits for CHD patients with low SES indicate that broadening accessibility of lifestyle programs through health insurance should be strongly encouraged.

Socioeconomic position and cardiovascular disease in adults with and without diabetes: United States trends, 1997-2005

BACKGROUND

Diabetes and its cardiovascular complications are more common in adults of low socioeconomic position (SEP). In the US, the past decade has seen the establishment of many programs to reduce cardiovascular risk in persons with diabetes, but their effect on socioeconomic disparities is uncertain.

OBJECTIVE

We sought to investigate recent time trends in socioeconomic disparities in cardiovascular disease (CVD) among persons with and without diabetes.

PARTICIPANTS AND DESIGN

Two hundred fifty-five thousand nine hundred sixty-six individuals aged 25 years or older included in the National Health Interview Survey between 1997 and 2005.

MEASUREMENTS

Educational attainment was used as a marker for SEP and self-reported history of CVD as the main outcome. Educational disparities were measured using prevalence rate ratios (PRR) and the relative index of inequalities (RII).

MAIN RESULTS

Among adults with diabetes, CVD prevalence was persistently higher in those who did not complete high school (HS) than in college graduates (adjusted PRR [aPRR] 1.20, 95% confidence interval [95%CI] 1.05-1.38 in 1997-1999, and aPRR 1.12, 95% CI 1.00-1.25 in 2003-2005). However, the HS vs. college graduates disparity in CVD declined from 1997-1999 (aPRR 1.20, 95% CI 1.04-1.37) to 2003-2005 (aPRR 1.01, 95% CI 0.90-1.12). Among adults without diabetes educational disparities in CVD widened markedly over time.

CONCLUSIONS

Concurrently with improvements in diabetes management, the widening of socioeconomic health disparities has remained limited in the diabetic population during the past decade. This provides evidence for the potential impact of improvements in disparities in health care access and process, such as experienced among persons with diabetes, in limiting socioeconomic health disparities.

Impaired glucose regulation and type 2 diabetes in children and adolescents

Diabetes mellitus in paediatric patients used to be almost exclusively type 1, but in recent years, case series as well as hospital-based and population-based studies indicated that the number of children and adolescents with type 2 diabetes (T2DM) has been increasing. This development is alarming since T2DM in youth is usually not an isolated condition, but accompanied by other cardiovascular risk factors such as obesity, dyslipidaemia, hypertension and low-grade inflammation. In adults, numerous studies provided detailed data on prevalence, incidence and risk factors for the development of T2DM, but for children and adolescents clinical and experimental data are still rather limited. This review provides an overview about the epidemiology and pathogenesis of T2DM in youth and about impaired glucose regulation as major risk factor for diabetes development with a special focus on the recent literature on clinical and lifestyle-related risk factors. Differences in incidence and prevalence across different populations indicate that ethnic background and genetic pre-disposition may be important risk determinants. In addition, epigenetic factors and foetal programming appear to confer additional risk before birth. Among the environmental and lifestyle-related risk factors there is evidence that obesity, hypercaloric diet, physical inactivity, socio-economic position (SEP), smoking, low-grade inflammation, psychosocial stress and sleeping patterns contribute to the risk for T2DM. However, the assessment of the relevance of risk factors and of incidence or prevalence estimates in youth is complicated by methodological issues that are also discussed.

Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes.

RESEARCH DESIGN AND METHODS

This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants' ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes).

RESULTS

After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01.

CONCLUSIONS

Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

Racial/ethnic and educational-level differences in diabetes care experiences in primary care

AIMS

To assess potential racial/ethnic and educational-level differences in the degree to which patients with diabetes who receive primary care from a Veterans Affairs Medical Center report that experiences with the diabetes care system are consistent with the Chronic Care Model (CCM).

METHODS

A cross-sectional mailed survey of 296 patients included the Patient Assessment of Chronic Illness Care (PACIC), which measures components of the care system suggested by the CCM.

RESULTS

Among 189 patients with complete information, non-white veterans had more than twice the odds of indicating that their diabetes care experience is in line with the CCM [measured by overall PACIC score > or =3.5] (OR 2.3; 95% CI 1.3-4.1). Non-white veterans were more likely to report high levels of assistance with problem solving and follow-up. Patients not completing high school had three times the odds of reporting care in line with the CCM (OR 3.0; 95% CI 1.2-7.6). Associations were also seen with implementation of the CCM in the areas of patient activation, perceived care teams, collaborative goal setting, and collaborative problem solving.

CONCLUSIONS

Non-white patients and those with less than a high school education had more than twice the odds of reporting that the diabetes care system is in line with the CCM.

The association of life course socio-economic position with diagnosis, treatment, control and survival of women with diabetes: findings from the British Women's Heart and Health Study

OBJECTIVES

To examine the association of socio-economic position (SEP) with the diagnosis, treatment and control of diabetes, and with survival in women with and without Type 2 diabetes.

METHODS

Prospective cohort study of 4277 women from 23 centres in Great Britain, aged 60-79 years at baseline.

RESULTS

Of the 4277 women, 220 (5.1%) were known to have Type 2 diabetes and a similar number [n = 188 (4.4%)] had undiagnosed diabetes based on a single fasting glucose level > or = 7.0 mmol/l. Neither childhood nor adult SEP was associated with being correctly diagnosed amongst the 408 women with either diagnosed or undiagnosed diabetes. In both women with and without diabetes, SEP was associated with more adverse levels of fasting insulin, triglycerides, high-density lipoprotein cholesterol and body mass index, but was not associated with glycated haemoglobin in either group. Over the follow-up period, 395 women died. The hazard ratio for all-cause mortality per additional indicator of adverse SEP in adulthood in women with diabetes [1.40 (1.05, 1.85)] was similar to that in women without diabetes [1.26 (1.12, 1.41], P for difference in the two estimates = 0.70). Childhood SEP was not associated with survival.

CONCLUSION/INTERPRETATION

A considerable number of older women with Type 2 diabetes are not diagnosed, but SEP is not related to being correctly diagnosed. The marked socio-economic gradient for all-cause mortality is the same for women with and without diabetes and is not fully explained by conventional risk factors.

Getting the social organism thinking: strategy for systems change

The ability of community researchers/practitioners to facilitate systems change is constrained by social power--particularly the capacity to shape ideology [S. Lukes (1974). Power: A radical view. Hampshire: MacMillan] and frequently power molds ideologies which undermine systems thinking. Following what Mills [C. W. Mills, (1959). The sociological imagination. New York: Oxford University Press] (termed the "sociological imagination", this article makes the case for a strategy of systems change that promotes an integrated focus on systems and their constituent individuals. Both of these components are understood to continuously shape each other. The social imagination is introduced as a way to conceptualize the intersection between individuals' conceptions of systems and the ways that systems work to form individual identities and perceptions of social reality. Examples of attempts at systems change from community organizing and public health are used to illustrate both common fallacies and potential future directions for systems change efforts.

Dentists' management of the diabetic patient: contrasting generalists and specialists

OBJECTIVES

We measured and contrasted general dentists' and periodontists' involvement in 3 areas of managing diabetic patients-assessment of health status, discussion of pertinent issues, and active management of patients--and identified and contrasted predictors of active management of diabetic patients.

METHODS

We conducted a cross-sectional mail survey of random samples of general dentists and periodontists in the northeastern United States during fall 2002, using lists from the 2001 American Dental Directory and the 2002 American Academy of Periodontology Directory. Responses were received from 105 of 132 eligible general dentists (response rate=80%) and from 103 of 142 eligible periodontists (response rate=73%).

RESULTS

Confidence, involvement with colleagues and medical experts, and professional responsibility were influential predictors of active management for periodontists (R2=0.46, P<.001). Variables pertaining to patient relations were significant predictors for general dentists (R2=0.55, P<.001).

CONCLUSIONS

Our findings permitted us to assess and compare general dentists' and periodontists' behavior in 3 realms--assessment of diabetic patients' health status, discussion of pertinent issues, and active management of diabetic patients--and to identify components of potentially effective targeted interventions aimed at increasing specialists' and generalist dentists' involvement in the active management of diabetic patients.

Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the women's health initiative: a cross-sectional analysis

OBJECTIVES

We sought to assess the extent to which race/ethnicity and socioeconomic status (SES) are independently and jointly related to lifetime morbidity burden by comparing the impact of SES on lifetime morbidity among women of different racial/ethnic groups: white, black, Hispanic, American Indian/Alaska Native (AIAN), and Asian/Pacific Islander (API).

METHODS

Using baseline data from the Women's Health Initiative (WHI), a national study of 162,000 postmenopausal women, we measured lifetime morbidity burden using a modified version of the Charlson Index, and measured SES with educational attainment and household income. In multivariable simple polytomous logistic regression models, we first assessed the effect of SES on lifetime morbidity burden among women of each racial/ethnic group, then assessed the combined effect of race/ethnicity and SES.

RESULTS

Five percent of all women in the study population had high lifetime morbidity burden. Women with high lifetime morbidity were more likely to be AIAN or black; poor; less educated; divorced, separated, or widowed; past or current smokers; obese; uninsured or publicly insured. Lower SES was associated with higher morbidity among most women. The extent to which morbidity was higher among lower SES compared to higher SES women was about the same among Hispanic women and white women, but was substantially greater among black and AIAN women compared with white women.

CONCLUSIONS

This study demonstrates the importance of considering race/ethnicity and class together in relation to health outcomes.

Diabetes and Thyroid Disease: Nursing Care to Improve Outcomes for Patients Living in Poverty

A primary goal of nurses providing care for persons who have diabetes mellitus or thyroid disease is improving their health outcomes. For persons who have diabetes and thyroid disease and live in poverty, improving the care process, and ultimately health outcomes, must include the nurse's understanding of poverty. The purpose of this article is to provide nurses with a basic understanding of the resource issues, "hidden rules," and characteristics that are associated with persons who live in poverty. Most importantly, some basic strategies to improve the health outcomes of patients who have diabetes or thyroid disease and live in poverty are provided.

Impact of self-reported patient characteristics upon assessment of glycemic control in the Veterans Health Administration

OBJECTIVE

The purpose of this article was to evaluate the impact of self-reported patient factors on quality assessment of Veterans Health Administration medical centers in achieving glycemic control.

RESEARCH DESIGN AND METHODS

We linked survey data and administrative records for veterans who self-reported diabetes on a 1999 national weighted survey. Linear regression models were used to adjust A1C levels in fiscal year 2000 for socioeconomic status (education level, employment, and concerns of having enough food), social support (marital status and living alone), health behaviors (smoking, alcohol use, and exercise level), physical and mental health status, BMI, and diabetes duration. Medical centers were ranked by deciles, with and without adjustment for patient characteristics, on proportions of patients achieving A1C <7 or <8%.

RESULTS

There was substantial medical center level variation in patient characteristics of the 56,740 individuals from 105 centers, e.g., grade school education (mean 15.3% [range 2.3-32.7%]), being retired (38.3% [19.9-59.7%]) or married (65.2% [43.7-77.8%]), food insufficiency (13.9% [7.2-24.6%]), and no reported exercise (43.2% [31.1-53.6%]). The final model had an R(2) of 7.8%. The Spearman rank coefficient comparing the thresholds adjusted only for age and sex to the full model was 0.71 for <7% and 0.64 for <8% (P < 0.0001). After risk adjustment, 4 of the 11 best-performing centers changed at least two deciles for the <7% threshold, and 2 of 11 changed two deciles for the <8% threshold.

CONCLUSIONS

Adjustment for patient self-reported socioeconomic status and health impacts medical center rankings for glycemic control, suggesting the need for risk adjustment to assure valid inferences about quality.

Inégalités de santé et d'accès secondaire aux soins

The role of health care inequalities in social inequalities in health should be reconsidered since the quality of health care varies according to the social status. Some of the health care inequalities are constructed by not taking account of health inequalities in the development of programs or recommendations of medical practice and thus ending up with management procedures that do not reduce inequalities to a minimum but even contribute to increasing them. Other health care inequalities are due to omission, linked to the operating inertia of a health care system that does not recognize these inequalities and has no plan to catch them up. To reverse this situation it seems necessary to act at the three levels of the health care system: to change the clinical paradigm at the micro level, tackle the organizations issues at the meso level, and pursue the reform of the entire health care system at the macro level.

Perception of unmet basic needs as a predictor of physical functioning among community-dwelling older adults

OBJECTIVES

The present study examined the influence of participant's perception that their basic needs were not being met on their physical functioning problems. The association between lower social economic status (SES), typically indexed by income and education, and physical disability has been clearly established. Although income and education are not easily modifiable among older adults, perceptions of resource deficits may be more easily influenced through interventions.

METHOD

Among community-dwelling older adults (N = 4,162), the authors examined the influence of participants' perception that their basic needs were not being met on physical functioning problems during a 10-year period using growth curve analyses.

RESULTS

Baseline problems meeting basic needs influenced the growth in physical functioning problems, even after controlling for more objective indices of SES and for health problems and behaviors.

DISCUSSION

Interventions focused on providing older adults with resources for meeting basic needs may substantially reduce the subsequent level of disability.

Understanding the determinants of health for people with type 2 diabetes

OBJECTIVE

We assessed which of a broad range of determinants of health are most strongly associated with health-related quality of life (HRQL) among people with type 2 diabetes.

METHODS

Our analysis included respondents from the Canadian Community Health Survey Cycle 1.1 (2000-2001) who were aged 18 years and older and who were identified as having type 2 diabetes. We used regression analyses to assess the associations between the Health Utilities Index Mark 3 and determinants of health.

RESULTS

Comorbidities had the largest impact on HRQL, with stroke (-0.11; 95% confidence interval [CI] = -0.17, -0.06) and depression (-0.11; 95% CI = -0.15, -0.06) being associated with the largest deficits. Large differences in HRQL were observed for 2 markers of socioeconomic status: social assistance (-0.07; 95% CI=-0.12, -0.03) and food insecurity (-0.07; 95% CI=-0.10, -0.04). Stress, physical activity, and sense of belonging also were important determinants. Overall, 36% of the variance in the Health Utilities Index Mark 3 was explained.

CONCLUSION

Social and environmental factors are important, but comorbidities have the largest impact on HRQL among people with type 2 diabetes.

Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes

OBJECTIVES

We sought to determine whether literacy mediates the relationship between education and glycemic control among diabetes patients.

METHODS

We measured educational attainment, literacy using the Short Test of Functional Health Literacy in Adults (s-TOFHLA), and glycemic control (HbA1c) in 395 diabetes patients at a U.S. public hospital. We performed path analysis to compare two competing models to explain glycemic control. The direct effects model estimated how education was related to HbA1c; the mediational model estimated the strength of the direct relationship when the additional pathway from education to literacy to HbA1c was added.

RESULTS

Both the model with a direct effect of education on HbA1c and the model with literacy as a mediator were supported by good fit to observed data. The mediational model, however, was a significant improvement, with the additional path from literacy to HbA1c reducing the discrepancy from observed data (p < 0.01). After including this path, the direct relationship between education and HbA1c fell to a non-significant threshold.

CONCLUSIONS

In a low-income population with diabetes, literacy mediated the relationship between education and glycemic control. This finding has important implications for both education and health policy.

La diabetes mellitus en España: mortalidad, prevalencia, incidencia, costes económicos y desigualdades

OBJECTIVE

Describing the situation of diabetes mellitus (DM) in Spain from a public health perspective.

MATERIAL AND METHOD

manual review of books and other documents on diabetes mellitus in Spain was conducted. In addition, a specific research of articles published using MeSH terms diabetes mortality, prevalence, incidence, cost, inequalities and Spain was conducted in Medline through Internet (PubMed). Minimun Basic Data Set was utilized as source for complication description by Communities Autonomus.

RESULTS

DM is one of the leading cause of mortality and the third one in women. With regard to Autonomous Communities, Canary Islands, Ceuta y Melilla and Andalusia show the greatest mortality with a downward trend. Diabetics present greater mortality than non diabetic patients, being complications the main cause of the over-mortality, especially ischemic heart disease. Estimations of prevalence for DM2 range from 4.8% to 18.7% and for DM1, from .08% to .2%. In pregnancy, it has been noted a prevalence ranging from 4.5% to 16.1%. With respect to incidence per year, it is estimated a range from 146 to 820 per 100,000 inhabitants for DM2 and a range from 10 to 17 new cases annually per 100,000 inhabitants for DM1. Costs for DM1 show very different results, averaging between 1,262 and 3,311 euro per people and year. There are differences for DM2 costs as well, averaging between 381 and 2,560 euro per patient and year. Total costs estimated range from 758 to 4,348 euro per person and year. Relationship between a low socioeconomic level (LSL) and DM2 risk has been proved. Moreover, it has been noted that the less LSL the worse is the disease control, coupled with a greater frequency and more frequent factors of DM2 risk.

CONCLUSIONS

The knowledge about the situation of the DM as a Public Health problem in Spain is limited. Mortality data available does not gather its real magnitude, and prevalence, incidence, costs and inequalities research are very poor and hardly comparable. In spite of this degree of incertitude, we can state that DM is an important public health problem with a continuous increase, especially DM2, if the appropriate prevention and control measures are not taken.

Socioeconomic status and stroke

This paper reviews the current evidence for the association between socioeconomic status and stroke incidence, survival, mortality, and other outcomes. The evidence is strongest for mortality and incidence of stroke, with high rates of stroke in low socioeconomic groups being a consistent finding. Low socioeconomic groups also have lower survival and greater stroke severity than high socioeconomic groups, although there is less evidence for this association. The mechanisms through which socioeconomic status affects stroke risk and outcomes are unclear but some studies report that differences in risk-factor prevalence could account for some of the variation. We discuss the implications of these findings and make recommendations for future research. Studies using prospective population-based methods with improved control for confounding factors are needed to confirm or refute these associations. Understanding the causal associations between socioeconomic status and stroke will allow interventions to be appropriately targeted and assessed.

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.

Association among individual deprivation, glycemic control, and diabetes complications: the EPICES score

OBJECTIVE

Previous studies have related poor glycemic control and/or some diabetes complications to low socioeconomic status. Some aspects of socioeconomic status have not been assessed in these studies. In the present study, we used an individual index of deprivation, the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé (Evaluation of Precarity and Inequalities in Health Examination Centers [EPICES]) score, to determine the relationship among glycemic control, diabetes complications, and individual conditions of deprivation.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional prevalence study in 135 consecutive diabetic patients (age 59.41 +/- 13.2 years [mean +/- SD]) admitted in the hospitalization unit of a French endocrine department. Individual deprivation was assessed by the EPICES score, calculated from 11 socioeconomic questions. Glycemic control, lipid levels, blood pressure, retinopathy, neuropathy, and nephropathy were assessed.

RESULTS

HbA(1c) level was significantly correlated with the EPICES score (r = 0.366, P < 0.001). The more deprived patients were more likely than the less deprived patients to have poor glycemic control (beta = 1.984 [SE 0.477], P < 0.001), neuropathy (odds ratio 2.39 [95% CI 1.05-5.43], P = 0.037), retinopathy (3.66 [1.39-9.64], P = 0.009), and being less often admitted for 1-day hospitalization (0.32 [0.14-0.74], P = 0.008). No significant relationship was observed with either nephropathy or cardiovascular risk factors.

CONCLUSIONS

Deprivation status is associated with poor metabolic control and more frequent microvascular complications, i.e., retinopathy and neuropathy. The medical and economic burden of deprived patients is high.

The socioeconomic correlates of global complication prevalence in type 1 diabetes (T1D): a multinational comparison

We sought to determine the extent to which the geographic variation in the complications of type 1 diabetes (T1D) may reflect the socioeconomic status (SES) conditions and health care performance (HCP) of countries around the world. The World Health Organization (WHO) DiaMond complications study (DiaComp) is a multinational, cross-sectional study of complications in T1D. Information on complications was identified for 892 subjects from 14 clinical centers in 12 countries. All participants were diagnosed with diabetes in childhood (<15 years of age) and had disease duration of 5-24 years. Complications were assessed by self-report, and by clinical exam, with microalbuminuria identified by Micral II dipstick, neuropathy by the Michigan Neuropathy Screening Instrument exam and hypertension using the HDFP protocol. These data were linked to center-specific information on the local social and economic landscape, health care access and diabetes management practices and health care costs. Country-specific indicators of social and economic development were also linked to the complications data. Both diabetes complications and economic and health care factors vary widely across the DiaComp centers. Health system performance, as measured by disability adjusted life expectancy (DALE), gross national investment (GNI) per capita and purchasing power all showed strong consistent correlations with complications, and significant independent associations with complication prevalence after controlling for HbA1c and hypertension. In conclusion, health system performance, social distribution of wealth and purchasing power may play important roles in explaining the geographic variation of diabetes complications.