Comparison of processes and intermediate outcomes between South Asian and European patients with diabetes in Blackburn, north-west England

Systematic review and meta-analysis of patient race/ethnicity, socioeconomics, and quality for adult type 2 diabetes

OBJECTIVE

To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics.

DATA SOURCE

Studies of adult patients with type 2 diabetes in MEDLINE published between January 1, 2000, and December 31, 2018.

STUDY DESIGN

Systematic review and meta-analysis of regression-based studies including race/ethnicity and income or education as explanatory variables. Meta-analysis was used to quantify differences in performance associated with patient race/ethnicity or socioeconomic characteristics. The systematic review was used to identify potential mechanisms of disparities.

DATA COLLECTION

Two coauthors separately conducted abstract screening, study exclusions, data extraction, and scoring of retained studies. Estimates in retained studies were extracted and, where applicable, were standardized and converted to odds ratios and standard errors.

PRINCIPAL FINDINGS

Performance in intermediate outcomes and process measures frequently exhibited differences by race/ethnicity even after adjustment for socioeconomic, lifestyle, and health factors. Meta-analyses showed black patients had lower odds of HbA1c and blood pressure (BP) control (OR range: 0.67-0.68, P < .05) but higher odds of receiving eye or foot examination (OR range: 1.22-1.47, P < .05) relative to white patients. A high school degree or more was associated with higher odds of HbA1c control and receipt of eye examinations compared to patients without a degree. Meta-analyses of income included a handful of studies and were inconsistently associated with diabetes care performance. Differences in diabetes performance appear to be related to access-related factors such as uninsurance or lacking a usual source of care; food insecurity and trade-offs at very low incomes; and lower adherence among younger and healthier diabetes patients.

CONCLUSIONS

Patient race/ethnicity and education were associated with differences in diabetes quality measures. Depending on the approach used to rate providers, not adjusting for these patient characteristics may penalize or reward providers based on the populations they serve.

Predictors of poor glycemic control in adult with type 2 diabetes in South-Eastern Nigeria

BACKGROUND

The study investigated predictors of poor glycemic control in type 2 diabetes (T2DM).

METHODS

Data on demographics, anthropometric and clinical parameters were collected in a cross-section survey from 140 adults with T2DM, using standard tools/instruments. Glycated hemoglobin (A1C) was assessed as a measure of glycemic control.

RESULTS

Majority (83.3%) had poor glycemic control status of which about 95% constitute the elderly. The elderly (OR= 5.90, 95% Cl: 1.66-20.96) were more likely associated with poor glycemic control than the non-elderly (p = 0.006). Adjustment for significant predictor variables: Age, waist-hip ratio (WHR), Fasting plasma glucose (FPG) and Systolic blood pressure (SBP), although attenuated the odds (OR= 5.00, 95% CI: 1.19-20.96) of poor glycemic control, it still remained significantly (p = 0.028) higher in the elderly. Patients outside tight FPG control significantly (p = 0.001) showed poor glycemic cotrol than those within tight FPG (OR= 17.39, 95%Cl: 5.83-51.90), even with attenuated OR (OR= 10.85, 95%Cl: 3.10-37.96) and (OR=12.08, 95%Cl: 3.64-40.09) when non-significant and significant predictor variables were accounted for, respectively.

CONCLUSION

Age, WHR, FPG, and SBP were significantly associated with differences in glycemic control. The elderly and FPG outside tight control showed significantly increased odds of poor glycemic control status.

Risk factors and outcome differences in hypoglycaemia-related hospital admissions: A case-control study in England

AIMS

To evaluate risk factors for hospital admissions for hypoglycaemia and compare length of hospitalization, inpatient mortality and hospital readmission between hypoglycaemia- and non-hypoglycaemia-related admissions.

MATERIALS AND METHODS

We used all admissions for hypoglycaemia in individuals with diabetes to English NHS hospital trusts between 2005 and 2014 (101 475 case admissions) and 3 random admissions per case in individuals with diabetes without hypoglycaemia (304 425 control admissions). Risk factors and differences in the 3 outcomes were estimated with logistic and negative binomial regressions.

RESULTS

A U-shaped relationship between age and risk of admission for hypoglycaemia was observed until the age of 85 years; compared to the nadir at 60 years, the risk was progressively higher in younger and older patients and steadily declined after 85 years. Social deprivation (positively) and comorbidities (negatively) were associated with the risk of admission for hypoglycaemia. Compared to Caucasians, other ethnic groups had lower (Bangladeshi, Pakistani, Indians) or higher (Caribbean) risk of admission for hypoglycaemia. Length of hospitalization was 26% shorter while risk of rehospitalization was 65% higher in individuals admitted for hypoglycaemia. Compared to admissions for hypoglycaemia, risk of inpatient mortality was 50% lower for unstable angina but higher for acute myocardial infarction (3 times), acute renal failure (5 times) or pneumonia (8 times).

CONCLUSIONS

Among hospital-admitted individuals with diabetes, age, social deprivation, comorbidities and ethnicity are associated with higher frequency of hospitalization for hypoglycaemia. Admission for hypoglycaemia is associated with a greater risk of readmission, a shorter length of hospitalisation and a generally lower inpatient mortality compared to admissions for other medical conditions. These results could help in identifying at-risk groups to reduce the burden of hospitalization for hypoglycaemia.

Lifestyle-tailored interventions for South Asians with type 2 diabetes living in high-income countries: a systematic review

AIM

To summarize evidence on the effectiveness of educational interventions for type 2 diabetes control in South Asians living in high-income countries.

METHODS

We systematically searched PubMed, EMBASE, Cinahl and the Cochrane Library, using Medical Subject Heading and free-text terms. The considered outcomes were: mortality, morbidity, glycaemic control, blood pressure, practice (diet, physical activity and self-care), attitudes/awareness and knowledge. Papers published up to July 2015 were considered. Two reviewers independently screened the title and abstract and then read the full text of selected papers.

RESULTS

Nine studies were included, four non-randomized studies of interventions and five randomized controlled trials. All studies except one were conducted in the UK. Target population ranged from 39 to 1486 individuals; the follow-up ranged from 1 to 24 months. The interventions were mostly based on a tailored educational package, individually or group administered, conducted by lay link workers, health professionals or both. No study measured mortality or morbidity. An effect on glycaemic control was observed only in before/after studies, while a randomized study showed a non-significant improvement (percentage of glycated haemoglobin -0.15, P = 0.11). Two randomized studies found a reduction in blood pressure. Changes in practice and attitudes showed heterogeneous results, mostly favouring intervention.

CONCLUSIONS

There was weak evidence that interventions using link workers and tailored education can modify attitudes, self-care skills and blood pressure in South Asian migrants to industrialized countries. Only one larger trial, with adequate follow-up, showed a small non-significant improvement of glycaemic control.

An alternative approach to modelling HbA1c trajectories in patients with type 2 diabetes mellitus

AIMS

Time-dependent HbA1c trajectories in health economic models of type 2 diabetes mellitus (T2DM) are typically informed by the UK Prospective Diabetes Study (UKPDS). However, this approach may not accurately predict HbA1c progression in patients who do not conform to the demographic profile of the original UKPDS cohort. This study aimed to develop an alternative mathematical model (MM) to simulate HbA1c progression in T2DM.

MATERIALS AND METHODS

A systematic literature review identified studies, published between 2005 and 2015, that reported HbA1c in adult T2DM patients over a minimum duration of 18 months. Pooled data from eligible studies were used to develop an alternative MM equation for HbA1c progression, which was then contrasted with the UKPDS 68 progression equation in illustrative scenarios.

RESULTS

A total of 68 studies were eligible for data extraction (mean follow-up time 4.1 years). HbA1c progression was highly heterogeneous across studies, varying with baseline HbA1c, treatment group and patient age. The MM equation was fitted with parameters for mean baseline HbA1c (8.3%), initial change in HbA1c (-0.62%) and upper quartile of maximum observed HbA1c (9.3%). Differences in HbA1c trajectories between the MM and UKPDS approaches altered the timing of therapy escalation in illustrative scenarios.

CONCLUSIONS

The MM represents an alternative approach to simulate HbA1c trajectories in T2DM models, as UKPDS data may not adequately reflect the heterogeneity of HbA1c profiles observed in clinical studies. However, the choice of approach should ultimately be determined by the characteristics of individual patients under consideration and the clinical face validity of the modelled trajectories.

Differences in diabetes prevalence and inequalities in disease management and glycaemic control by immigrant status: a population-based study (Italy)

Background

The diabetes prevalence increases at an alarming rate around the world and understanding disparities in occurrence, care management, and health outcomes may be a starting point towards achieving more effective strategies to prevent and manage it. The aims of this study are to compare immigrants and Italians in terms of the differences in diabetes prevalence and to evaluate inequalities in disease management and glycaemic control by using information included in Reggio Emilia diabetes register.

Methods

We retrieved from the diabetes register subjects aged 20–74 on December 31^st, 2009. Using citizenship, we created three main groups: Italy, High Developed Countries (HDC), and High Migration Pressure Countries (HMPC). These were split into sub-regions of origin. We calculated age-adjusted prevalence by gender and sub-region. Using logistic regression model, we analyzed the association between area of origin and following indicators: 1) not being in care of diabetes clinics; 2) not having glycated haemoglobin (HbA1c) test in 2010; 3) among those tested, having a HbA1c value > = 9% (75 mmol/mol).

Results

We found 15,889 Italian and 1,295 HMPC citizens with diabetes. HMPC citizens had higher age-adjusted prevalence of diabetes than Italians (females 5.0% vs 3.6%; males 6.5% vs 5.5%). The excess was mostly due to a strong excess in immigrants from Southern Asia (females 9.7%, males 10.2%) and Northern Africa (females 9.3%, males 5.9%). HMPC citizens were cared for by diabetes clinics in a similar proportion than Italians (OR: 1.08; 95% CI: 0.93-1.25), but had a greater odds of not being tested for HbA1c (OR: 1.51; 95% CI: 1.34-1.71), as well as of having HbA1c values equal to or over 9% (OR: 2.06; 95% CI: 1.80-3.14). The outcomes were poorer in HMPC females for the first two outcomes, while there was no difference for the HbA1c values (Wald test for heterogeneity p = 0.0850; p = 0.0156; p = 0.6635, respectively).

Conclusions

Our findings highlight the need for gender-oriented actions for prevention and early diagnosis of the diabetes to contrast the higher risk in Northern Africans and Southern Asians. Further studies are required to determine whether the protocols in use are adequate for different immigrant groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1403-4) contains supplementary material, which is available to authorized users.

Management of type 2 diabetes in Asian Indians: a review of the literature

Type 2 diabetes mellitus (T2DM) is increasing in Asian Indians globally. In this article, we review published studies of interventions designed to prevent T2DM or improve self-management in South Asian Indians. A PubMed, CINAHL, Medline, EMBASE, Psycinfo, Family & Society Studies Worldwide, Web of Science, and Consumer Health Complete search was conducted using the following search terms: type 2 diabetes mellitus, Asian Indian continental ancestry group, therapy, treatment, management, care, intervention, self-care, exercise, diet, and lifestyle. The review included pilot or full intervention studies examining the prevention and/or management of T2DM and qualitative studies analyzing the influence of various ethnic factors on the prevention and management of T2DM. Seventeen studies met the inclusion criteria. They examined the influence of culture and religion and the effectiveness of individual and community-based education and lifestyle improvement programs, exercise, and complementary therapies. Few programs led to the improved long-term management of T2DM. Further research is needed to develop ethnic-specific interventions.

Ethnic differences in glycaemic control in people with type 2 diabetes mellitus living in Scotland

Background and Aims

Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland

Methods

We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes.

Results

Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p<0.05) greater proportions of people with suboptimal glycaemic control (HbA1c >58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively.

Conclusions

Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.

Culturally competent interventions in Type 2 diabetes mellitus management: an equity-oriented literature review

OBJECTIVES

Although, culturally competent (CC) interventions aim to reduce health inequalities for ethnic minorities, they have been criticized on the grounds that they increase prejudice and stereotyping. It remains unclear whether CC interventions really can reduce health inequalities among ethnic minorities. The purpose of this review is to assess whether CC interventions in the management of Type 2 diabetes mellitus (T2DM) match the recommendations to reduce health inequalities.

DESIGN

We identified CC interventions relating to T2DM among ethnic minority patients in the literature published between 2005 and 2011. Data were analyzed according to an equity-oriented framework. Each study was given a score based on its congruence with the reduction of health inequalities amongst ethnic minorities.

RESULTS

We reviewed 137 papers and found 61 studies that met the inclusion criteria. Most interventions focused on the individual level and the modification of patients' health behavior. Very few addressed the sociopolitical level. A minority of the studies acknowledged the role of socioeconomic deprivation in ethnic health inequalities. Half of the studies contained no information about the socioeconomic status of the patients. The patients receiving the interventions were socioeconomically deprived. Only 10 studies compared ethnic minority groups to majority groups. Thirty-three studies had a very low average congruence score. The highest score of congruence was achieved by one study.

CONCLUSION

Overall, CC interventions addressing T2DM are not congruent with the reduction of ethnic health inequalities. The future of CC interventions may involve going one step further and going back to basic tenets of cultural competence: the integration of difference, whatever its source, into the delivery of fair health care for patients.

Pharmacological primary and secondary cardiovascular prevention among diabetic patients in a multiethnic general practice population: still room for improvements

BACKGROUND

Ethnic minority groups have higher prevalence of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). We assessed general practitioners' (GPs') performance with respect to the pharmacological prevention of CVD in patients with T2DM from different ethnic backgrounds in Oslo.

METHODS

Of 1653 T2DM patients cared for by 49 GPs in 2005, 380 had a diagnosis of CVD. Ethnicity was categorized as Norwegian, South Asian and other. Risk factor levels, medication use, achievement of treatment targets (HbA1c ≤ 7.5%, systolic blood pressure (SBP) ≤ 140 mmHg, total cholesterol/HDL-cholesterol < 4) and therapeutic intensity (number of drugs targeting each risk factor) were recorded. Chi-square, Wald tests and multiple linear regression analyses were used.

RESULTS

Of the 1273 patients receiving primary prevention, 1.5% had their Hb1Ac, 4.8% SBP and 12.7% lipids levels above treatment thresholds without relevant prescriptions. Among patients on pharmacological therapy, 66% reached the HbA1c, 62% SBP and 62% lipid target. Proportions not achieving the HbA1c target were 26% in Norwegians, 38% in South Asians and 29% in others (p = 0.008). Proportions not achieving the SBP target were 42% in Norwegians, 22% in South Asians and 25% in others (p ≤ 0.001). Of those not achieving the HbA1c and SBP targets, 43% and 35% respectively, used only one agent.

CONCLUSIONS

Norwegian GPs comply reasonably well with guidelines for pharmacological prevention of CVD in T2DM patients across ethnic groups. However, lipid-lowering therapy was generally underused, and the achievement of treatment targets for HbA1c in ethnic minorities and for BP in Norwegians could be improved.

Absence of disparities in the quality of primary diabetes care for South Asians and Chinese in an urban Canadian setting

OBJECTIVE

To examine whether quality of diabetes care is equitable for South Asian and Chinese patients in an urban Canadian setting.

RESEARCH DESIGN AND METHODS

Process and intermediate measures of quality of care were compared between 246 South Asians, 170 Chinese, and 431 patients from the general population with type 2 diabetes selected from 45 family physicians' practices.

RESULTS

A total of 61% of Chinese achieved A1C ≤7.0% versus 45% of South Asians and 49% of the general population (P < 0.05). They were also more likely to achieve LDL cholesterol ≤2.0 mmol/L, while South Asians were more likely to achieve blood pressure ≤130/80. There was only one significant process of care deficiency: fewer foot examinations among South Asians (34 vs. 49% for the general population, P < 0.01).

CONCLUSIONS

Quality of diabetes care in a Canadian urban setting was equitable, with ethnic minorities somewhat more likely to achieve recommended targets than the general population.

Support systems for and barriers to diabetes management in South Asians and Whites in the UK: qualitative study of patients' perspectives

OBJECTIVES

To explore experiences of UK-based South Asian and White patients with diabetes in relation to their support systems for and barriers to diabetes management.

DESIGN

Qualitative study (semistructured interviews analysed using a form of Interpretative Phenomenological Analysis).

PARTICIPANTS

20 outpatients with diabetes (12 British South Asians and 8 British Whites) with either good or poor glycaemic control.

SETTING

Hillingdon Hospital, Uxbridge, UK.

RESULTS

Qualitative analysis revealed distinct themes for the two ethnic groups. For the South Asian participants, challenges surrounding diet management and social stigma attached to having diabetes were the two predominant barriers to effective diabetes management. Support from immediate family members was commonly reported as a strong support system for optimising diabetes management by the South Asian sample in addition to the perceived positive impact of religion (healing power of prayer), the valuable informational support from their diabetes-care team, patient leaflets and diabetes magazines. Similar to the South Asians, adhering to dietary recommendations was the most difficult aspect of diabetes management for the White participants followed by the inconveniences surrounding injecting insulin. The hospital diabetes-care team was considered as the most effective support system for diabetes management by the White sample and interestingly, this was the only dominant theme in their reported sources of support.

CONCLUSIONS

Both South Asian and White participants emphasised adherence to dietary recommendations as the most difficult aspect of living with diabetes. In addition, social stigma attached to diabetes was a prominent concern among South Asian participants that seemed to have a significant negative impact on their diabetes control and overall management. Given South Asian patients' reliance on their family for the management of their condition, interventions targeting improved diabetes outcomes in this population may prove more successful if they are designed to involve significant family members.

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

Quality of care for patients with type 2 diabetes in general practice according to patients' ethnic background: a cross-sectional study from Oslo, Norway

Background

In recent decades immigration to Norway from Asia, Africa and Eastern Europe has increased rapidly. The aim of this study was to assess the quality of care for type 2 diabetes mellitus (T2DM) patients from these ethnic minority groups compared with the care received by Norwegians.

Methods

In 2006, electronic medical record data were screened at 11 practices (49 GPs; 58857 patients). 1653 T2DM patients cared for in general practice were identified. Ethnicity was defined as self-reported country of birth. Chi-squared tests, one-way ANOVAs, multiple regression, linear mixed effect models and generalized linear mixed models were used.

Results

Diabetes was diagnosed at a younger age in patients from the ethnic minority groups (South Asians (SA): mean age 44.9 years, Middle East/North Africa (MENA): 47.2 years, East Asians (EA): 52.0 years, others: 49.0 years) compared with Norwegians (59.7 years, p < 0.001). HbA1c, systolic blood pressure (SBP) and s-cholesterol were measured in >85% of patients in all groups with minor differences between minority groups and Norwegians. A greater proportion of the minority groups were prescribed hypoglycaemic medications compared with Norwegians (≥79% vs. 72%, p < 0.001). After adjusting for age, gender, diabetes duration, practice and physician unit, HbA1c (geometric mean) for Norwegians was 6.9% compared to 7.3-7.5% in the minority groups (p < 0.05). The proportion with poor glycaemic control (HbA1c > 9%) was higher in minority groups (SA: 19.6%, MENA: 18.9% vs. Norwegians: 5.6%, p < 0.001. No significant ethnic differences were found in the proportions reaching the combined target: HbA1c ≤ 7.5%, SBP ≤ 140 mmHg, diastolic blood pressure (DBP) ≤ 85 mmHg and total s-cholesterol ≤5.0 mmol/L (Norwegians: 25.5%, SA: 24.9%, MENA: 26.9%, EA: 26.1%, others:17.5%).

Conclusions

Mean age at the time of diagnosis of T2DM was 8-15 years younger in minority groups compared with Norwegians. Recording of important processes of care measures is high in all groups. Only one in four of most patient groups achieved all four treatment targets and prescribing habits may be sub-optimal. Patients from minority groups have worse glycaemic control than Norwegians which implies that it might be necessary to improve the guidelines to meet the needs of specific ethnic groups.

Improving care in cardiac rehabilitation for minority ethnic populations

INTRODUCTION

In the United Kingdom (UK) ethnic minority groups from the Indian sub-continent (India, Pakistan and Bangladesh) are at increased risk of coronary heart disease (CHD) related mortality and morbidity. The aim of this study was to assess the variation in recording of clinical data by ethnicity following the implementation of an electronic centralised cardiac rehabilitation register in the North West of England.

METHODS

Data were collected over 18 months for all individuals (n=1993) assessed for entry into the cardiac rehabilitation programme. Analysis of the recording of clinical data was undertaken by ethnicity with adjustment for gender, age group and deprivation.

RESULTS

Most patients on the database had their ethnicity recorded (94.4%). South Asians (Indian, Pakistani and Bangladeshi) were less likely to have clinical data items recorded compared to the majority White British group. The disparity in recording of clinical data was most marked for the Hospital Anxiety and Depression Scale score (adjusted OR 0.16, 95% CI 0.07-0.36), body mass index (adjusted OR 0.54, 95% CI 0.37-0.79), pulse (0.60, 95% CI 0.42-0.88), blood glucose (adjusted OR 0.64, 95% CI 0.44-0.93) and cholesterol (adjusted OR 0.64, 965% CI 0.44-0.95).

CONCLUSION

Recording of clinical data relevant to successful cardiac rehabilitation was poorer among South Asian patients.

Ethnic disparities in diabetes management: a 10-year population-based repeated cross-sectional study in UK primary care

BACKGROUND

There has been little research on the impact of quality improvement initiatives on ethnic disparities in diabetes management in the UK.

METHODS

Population-based, repeated cross-sectional survey of recorded measurements, prescribing and achievement of treatment targets among 4309 patients with diabetes mellitus using electronic medical records from 26 general practices in North-West London from 1997 to 2006.

RESULTS

Proportions of patients having their blood pressure (BP), cholesterol and HbA1c measured and recorded increased over the study period [from 50.6% to 87.0% (P < 0.0001), 17.0% to 76.7% (P < 0.0001) and 32.9% to 74.1% (P < 0.0001), respectively]. However, some ethnic differences remained. Black patients with diabetes were less likely to achieve target BP (<140/80 mmHg) than the white group [2006 age-sex adjusted odds ratio (AOR), 0.65; 95% confidence interval (CI), 0.51-0.83]. South Asians were found to have better lipid target control (2006 AOR, 1.57; CI, 1.23-2.00), were more likely to receive oral hypoglycaemic agents (2006 AOR, 2.27; CI, 1.79-2.86) but less likely to receive insulin (2006 AOR, 0.54; CI, 0.42-0.69) than the white group.

CONCLUSIONS

Although ethnic disparities persist in diabetes management in this study population, these are starting to be addressed, particularly in the South Asian group. All ethnic groups have benefited from recent quality initiatives in the UK.

Is there equity of service delivery and intermediate outcomes in South Asians with type 2 diabetes? Analysis of DARTS database and summary of UK publications

BACKGROUND

There are doubts whether diabetes care is equitable across UK ethnic groups. We examined processes and outcomes in South Asians with diabetes and reviewed the UK literature.

METHODS

We used name search methods to identify South Asians in a regional diabetes database. We compared prevalence rates, processes and outcomes of care between November 2003 and December 2004. We used standard literature search techniques.

RESULTS

The prevalence of diabetes in South Asians was 3-4 times higher than non-South Asians. South Asians were 1.11 times (95% confidence interval 1.06, 1.16) more likely to have a structured review. South Asian women were 1.10 times more likely to have a record of body mass index (95% CI 1.04, 1.16). HbA1c levels were 1.03 times higher (95% CI 1.00, 1.06) among South Asians, retinopathy 1.36 times more common (95% CI 1.03, 1.78) and hypertension 0.71 times as common (95% CI 0.58, 0.87).

CONCLUSIONS

We found evidence of equity in many aspects of diabetes care for South Asians in Tayside. The finding of higher HbA1c and more retinopathy among South Asians needs explanation and a service response. These findings from a region with a small non-White population largely support the recent findings from other parts of the UK.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Patients' acceptance of antihypertensive therapy to prevent cardiovascular disease: a comparison between South Asians and Caucasians in the United Kingdom

BACKGROUND

The importance of patients' involvement in decision-making is because of their right to know the risks and benefits they accept in undertaking treatment and the as yet unproven hope that this will improve compliance. The aim of this study was to establish local people's willingness to receive antihypertensive treatment for primary prevention of cardiovascular disease (CVD) and to explore the role of ethnicity.

METHODS

In a cross-sectional study with face-to-face interview South Asian and Caucasian men and women aged 35-74, with and without history of CVD, were interviewed. Minimal clinically important differences were measured for three different baseline CVD risks (10, 20, and 40% in 10 years) using a standard method with risks presented both graphically and numerically and expressed in positive and negative terms.

RESULTS

A total of 262 (110 South Asians) participants were interviewed. Overall, South Asians expressed smaller median minimal clinically important differences than Caucasians, 1 and 4%, respectively. Up to 17% of participants in both ethnic groups indicated that they would not take medication regardless of the benefits. The proportion of South Asian men unwilling to take medication regardless of benefit was higher than Caucasian men for all scenarios, 17.2 versus 10.7% for scenario 1 and 12.1 versus 5.6% for scenario 2, respectively. South Asians of both sexes who would consider therapy required less benefit for acceptance in all three scenarios compared with the Caucasians.

CONCLUSION

South Asian participants were at least likely as Caucasians to accept antihypertensive treatment as the primary prevention therapy and they should be targeted for this type of therapy.

Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross-sectional survey in primary care

BACKGROUND

The UK has a universal health care system that is free at the point of access. Over the past decade, the UK government has implemented an ambitious agenda of quality improvement initiatives in chronic disease management.

OBJECTIVE

To assess the quality of diabetes care and intermediate clinical outcomes within a multiethnic population after a sustained period of investment in quality improvement.

DESIGN

Population based cross-sectional survey, using electronic general practice records, carried out between November 2005 and January 2006.

PATIENTS

Seven thousand six hundred five adults (>or=18 years) with diabetes registered with 32 primary care practices.

MEASUREMENTS

Percentage achievement by ethnic group (black, south Asian, or white) of the quality indicators for diabetes in a new pay-for performance contract.

RESULTS

There were only modest variations in recording of process measures of care between ethnic groups, with no significant differences in recent measurement of blood pressure, HbA1c, cholesterol, micro-albuminuria, creatinine, or retinopathy screening attendance. Blacks and south Asians were significantly less likely to meet all three national treatment targets for diabetes (HbA1c <or= 7.4%, blood pressure <or= 145/85 mmHg, total cholesterol <or= 5 mmol/L [193 mg/dL]) than whites (25.3%, 24.8% , and 32.0%, respectively).

CONCLUSIONS

Our findings suggest that substantial investment in quality improvement initiatives in the UK may have led to more systematic and equitable processes of care for diabetes but have not addressed ethnic disparities in intermediate clinical outcomes.

Ethnic inequalities in the treatment and outcome of diabetes in three English Primary Care Trusts

Background

Although the prevalence of diabetes is three to five times higher in UK South Asians than Whites, there are no reports of the extent of ethnicity recording in routine general practice, and few population-based published studies of the association between ethnicity and quality of diabetes care and outcomes. We aimed to determine the association between ethnicity and healthcare factors in an English population.

Methods

Data was obtained in 2002 on all 21,343 diabetic patients registered in 99% of all computerised general practitioner (GP) practices in three NW London Primary Care Trusts (PCTs), covering a total registered population of 720,000. Previously practices had been provided with training, data entry support and feedback. Treatment and outcome measures included drug treatment and blood pressure (BP), total cholesterol and haemoglobin A1c (HbA1c) levels.

Results

Seventy per cent of diabetic patients had a valid ethnicity code. In the relatively older White population, we expected a smaller proportion with a normal BP, but BP differences between the groups were small and suggested poorer control in non-White ethnic groups. There were also significant differences between ethnic groups in the proportions of insulin-treated patients, with a smaller proportion of South Asians – 4.7% compared to 7.1% of Whites – receiving insulin, although the proportion with a satisfactory HbA1c was smaller- 25.6% compared to 37.9%.

Conclusion

Recording the ethnicity of existing primary care patients is feasible, beginning with patients with established diseases such as diabetes. We have shown that the lower proportion of South Asian patients with good diabetes control, and who are receiving insulin, is at least partly due to poorer standards of care in South Asians, although biological and cultural factors could also contribute. This study highlights the need to capture ethnicity data in clinical trials and in routine care, to specifically investigate the reasons for these ethnic differences, and to consider more intensive management of diabetes and education about the disease in South Asian patients.

Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study

BACKGROUND

Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.

METHODS AND FINDINGS

We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.

CONCLUSIONS

Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.