Socioeconomic inequalities in cardiometabolic control in patients with type 2 diabetes

Cohort Profile: CArdiovascular Risk in patients with DIAbetes in NAvarra (CARDIANA cohort)

PURPOSE

The CArdiovascular Risk in patients with DIAbetes in Navarra (CARDIANA cohort) cohort was established to assess the effects of sociodemographic and clinical variables on the risk of cardiovascular events in patients with type 1 (T1D) or type 2 (T2D) diabetes, with a special focus on socioeconomic factors, and to validate and develop cardiovascular risk models for these patients.

PARTICIPANTS

The CARDIANA cohort included all patients with T1D and T2D diabetes registered in the Public Health Service of Navarra with prevalent disease on 1 January 2012. It consisted of 1067 patients with T1D (ages 2-88 years) and 33842 patients with T2D (ages 20-105 years), whose data were retrospectively extracted from the Health and Administrative System Databases.

FINDINGS TO DATE

The follow-up period for wave 1 was from 1 January 2012 to 31 December 2016. During these 5 years, 9 patients (0.8%; 95% CI (0.4% to 1.6%)) in the T1D cohort developed a cardiovascular disease event, whereas for the T2D cohort, 2602 (7.7%; 95% CI (7.4% to 8.0%)) had an event. For the T2D cohort, physical activity was associated with a reduced risk of cardiovascular events, with adjusted estimated ORs equal to 0.84 (95% CI 0.66 to 1.07) for the partially active group and 0.71 (95% CI 0.56 to 0.91) for the active group, compared with patients in the non-active group.

FUTURE PLANS

The CARDIANA cohort is currently being used to assess the effect of sociodemographic risk factors on CV risk at 5 years and to externally validate cardiovascular predictive models. A second wave is being conducted in late 2022 and early 2023, to extend the follow-up other 5 years, from 1 January 2016 to 31 December 2021. Periodic data extractions are planned every 5 years.

Inequalities in glycemic and multifactorial cardiovascular control of type 2 diabetes: The Heart Healthy Hoods study

Aim

This study aimed to analyze glycemic control and multifactorial cardiovascular control targets in people with type 2 diabetes (T2DM) in primary care according to sex and socioeconomic status (SES).

Materials and methods

This is an observational, cross-sectional, and multicenter study. We analyzed all the patients with T2DMM aged between 40 and 75 years in Madrid city (113,265) through electronic health records from 01 August 2017 to 31 July 2018. SES was defined by an area-level socioeconomic index stratified by quintiles (1st quintile: more affluent).

Outcomes

Outcomes included glycemic control (HbA1c ≤ 7%), 3-factor cardiovascular control [HbA1c ≤ 7%, blood pressure (BP), < 140/90 mmHg, LDL < 100 mg/ml] and 4-factor control [HbA1c ≤ 7%, blood pressure (BP) < 140/90 mmHg, LDL < 100 mg/ml, and BMI < 30 kg/m²]. Multilevel logistic regression models analyzed factors associated with suboptimal glycemic control.

Results

In total 43.2% were women. Glycemic control was achieved by 63% of patients (women: 64.2% vs. men: 62.4%). Being more deprived was associated with suboptimal glycemic control (OR: 1.20, 95% CI: 1.10-1.32); however, sex was not related (OR: 0.97, 95% CI: 0.94-1.01). The optimal 3-factor control target was reached by 10.3% of patients (women: 9.3% vs. men: 11.2%), especially those in the 5th quintile of SES. The 4-factor control was achieved by 6.6% of the sample. In the 3-factor control target, being women was related to the suboptimal 3-factor control target (OR: 1.26, 95% CI: 1.19- 1.34) but only belonging to SES 4th quintile was related to the unachieved target (OR: 1.47, 95% CI: 1.04-2.07).

Conclusion

Suboptimal glycemic control was associated with being less affluent and suboptimal 3-factor control target was associated with being women.

Trends in glycemic control, cardiovascular risk factors and chronic complications of type 2 diabetes, 2012-2016, in a healthcare area of Barcelona

AIMS

This study aimed to analyse the evolution of the metabolic control, cardiovascular risk factors and chronic complications in a Type 2 Diabetes (T2D) population in a healthcare area of Barcelona.

METHODS

We carried out a comparative study of T2D patients (20.457) between 2012 and 2016 (data recorded in the "Electronic Clinical-Station in Primary Care") concerning: age, gender, body mass index (BMI), arterial blood pressure (BP), HbA1c, LDL-Cholesterol, smoking, heart failure (HF), micro and macrovascular complications.

RESULTS

Average HbA1c was 6.9 % in 2012 and 7 % in 2016 (Non significant differences)(NS). In 2012, 57.9 % of patients presented proper glycaemic control, 42.8 % LDL-Cholesterol < 100 mg/dL and 76.9 % BP < 140/90 while in 2016 it was 61.2 % (NS), 59.2 % (p = 0.001) and 82.9 % (p = 0.016) respectively. No changes were found in BMI or active smoking. Significant increases were found in the prevalence of microvascular complications, HF and peripheral vasculopathy (PV). Patients with vascular diseases (PVD) and adequate metabolic control increased from 57.5 % to 62.7 % (p = 0.006). Albuminuria > 30 mg/g were more frequent among PVD.

CONCLUSIONS

Between 2012 and 2016 it was observed that, amongst our study population, glycaemic control was steady and cholesterol and BP levels were improved, while there was a significant increase of diabetic complications, HF and PV.

Variability in the Control of Type 2 Diabetes in Primary Care and Its Association with Hospital Admissions for Vascular Events. The APNA Study

Type 2 diabetes (T2D) is associated with increased cardiovascular morbidity, mortality, and hospital admissions. This study aimed to analyze how the differences in delivered care (variability of glycosylated hemoglobin (HbA1c) achieved targets) affect hospital admissions for cardiovascular events (CVEs) in T2D patients. Methods: We analyzed the electronic records in primary care health centers at Navarra (Spain) and hospital admission for CVEs. We followed 26,435 patients with T2D from 2012 to 2016. The variables collected were age, sex, health center, general practitioner practice (GPP), and income. The clinical variables were diagnosis of T2D, weight, height, body mass index (BMI), blood pressure (BP), HbA1c, low-density lipoprotein cholesterol (LDL-C), smoking, and antecedents of CVEs. We calculated, in each GPP practice, the proportion of patients with HbA1c ≥ 9. A non-hierarchical K-means cluster analysis classified GPPs into two clusters according to the level of compliance with HbA1C ≥ 9% control indicators. We used logistic and Cox regressions. Results: T2D patients had a higher probability of admission for CVEs when they belonged to a GPP in the worst control cluster of HbA1C ≥ 9% (HR = 1.151; 95% CI, 1.032–1.284).

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review

Background

Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications.

Methods

PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias.

Results

Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams.

Conclusion

Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

[Diabetic patient control in Primary Care: Influence of service portfolio and other factors]

OBJECTIVE

To study the effect of the type of follow-up according to Service Portfolio and other associated factors, in the reduction of HbA1c levels in people with a new diagnosis of type 2 diabetes and poor initial control.

DESIGN

Analytical observational study of a cohort under routine clinical practice conditions.

LOCATION

262 Primary Health Care Centres in Madrid.

PARTICIPANTS

1,838 individuals older than 18 years with a new diagnosis of type 2 DM and initial HbA1c levels ≥ 7%, or ≥ 8.5% if older than 75 years.

INTERVENTIONS

The exposure variable was the type of follow-up according to Portfolio, categorised as minimum, medium, and optimal, according to the number of interventions performed and periodicity of type of therapeutic-pharmacological plan.

MAIN MEASUREMENTS

A study was made of the comorbidity, therapeutic-pharmacological plan, diet - exercise advice and deprivation index. The main outcome was the difference between the final and initial HbA1c.

RESULTS

After 2 years of follow-up there was a mean decrease in HbA1c by -1.7 percentage points (95% CI: -1.6;-1.8), which was 0.36 points higher in patients with optimal follow-up: -2.1 (95% CI: -1.7;-2.4). The factors associated with a decrease in HbA1c were the optimal follow-up -0.29 (95% CI: -0.5;-0.1), the medium follow-up -0.26 (95% CI: -0.5; -0.0), and the initial HbA1c value -0.9 (95% CI: -0.9; -0.9. The factors associated with the increase were insulin treatment and living in socially disadvantaged areas.

CONCLUSIONS

Glycaemic control was improved in patients with a new diagnosis of diabetes in which optimal follow-up is performed as proposed in the Service Portfolio.

Health Care Utilization of Homeless Minors With Diabetes in New York State From 2009 to 2014

OBJECTIVE

This study aims to describe differences in health care utilization between homeless and nonhomeless minors with diabetes.

RESEARCH DESIGN AND METHODS

Data from the Healthcare Cost and Utilization Project's Statewide Inpatient Database from New York for years 2009-2014 were examined to identify pediatric patients <18 years old with diabetes. Outcomes of interest included hospitalization rate, in-hospital mortality, admission through the emergency department (ED), diabetic ketoacidosis (DKA), hospitalization cost, and length of stay (LOS). Other variables of interest included age-group, race/ethnicity, insurance type, and year. Multivariate logistic regression models were used for in-hospital mortality, admission through ED, and DKA. Log-transformed linear regression models were used for hospitalization cost, and negative binomial regression models were used for LOS.

RESULTS

A total of 643 homeless and 10,559 nonhomeless patients were identified. The hospitalization rate was higher among homeless minors, with 3.64 per 1,000 homeless population compared with 0.38 per 1,000 in the nonhomeless population. A statistically significant higher readmission rate was detected among homeless minors (20.4% among homeless and 14.1% among nonhomeless, P < 0.01). Lower rates of DKA (odds ratio 0.75, P = 0.02), lower hospitalization costs (point estimate 0.88, P < 0.01), and longer LOS (incidence rate ratio 1.20, P < 0.01) were detected among homeless minors compared with nonhomeless minors.

CONCLUSIONS

This study found that among minors with diabetes, those who are homeless experience a higher hospitalization rate than the nonhomeless. Housing instability, among other environmental factors, may be targeted for intervention to improve health outcomes.

Socio-economic differences in cardiovascular disease risk factor prevalence in people with type 2 diabetes in Scotland: a cross-sectional study

AIM

To describe the association between socio-economic status and prevalence of key cardiovascular risk factors in people with type 2 diabetes in Scotland.

METHODS

A cross-sectional study of 264 011 people with type 2 diabetes in Scotland in 2016 identified from the population-based diabetes register. Socio-economic status was defined using quintiles of the area-based Scottish Index of Multiple Deprivation (SIMD) with quintile (Q)1 and Q5 used to identify the most- and least-deprived fifths of the population, respectively. Logistic regression models adjusted for age, sex, health board, history of cardiovascular disease and duration of diabetes were used to estimate odds ratios (ORs) for Q1 compared with Q5 for each risk factor.

RESULTS

The mean (sd) age of the study population was 66.7 (12.8) years, 56% were men, 24% were in Q1 and 15% were in Q5. Crude prevalence in Q1/Q5 was 24%/8.8% for smoking, 62%/49% for BMI ≥ 30 kg/m² , 44%/40% for HbA_1c ≥ 58 mmol/mol (7.5%), 31%/31% for systolic blood pressure (SBP) ≥ 140 mmHg, and 24%/25% for total cholesterol ≥ 5 mmol/l, respectively. ORs [95% confidence intervals (CI)] were 3.08 (2.95-3.21) for current smoking, 1.48 (1.44-1.52) for BMI ≥ 30 kg/m² , 1.11 (1.08-1.15) for HbA_1c ≥ 58 mmol/mol (7.5%), 1.03 (1.00-1.06) for SBP ≥ 140 mmHg and 0.87 (0.84-0.90) for total cholesterol ≥ 5 mmol/l.

CONCLUSIONS

Socio-economic deprivation is associated with higher prevalence of smoking, BMI ≥ 30 kg/m² and HbA_1c ≥ 58 mmol/mol (7.5%), and lower prevalence of total cholesterol ≥ 5 mmol/l among people with type 2 diabetes in Scotland. Effective approaches to reducing inequalities are required as well as reducing risk factor prevalence across the whole population.

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.

Inverse-probability weighting and multiple imputation for evaluating selection bias in the estimation of childhood obesity prevalence using data from electronic health records

Background and objectives

Height and weight data from electronic health records are increasingly being used to estimate the prevalence of childhood obesity. Here, we aim to assess the selection bias due to missing weight and height data from electronic health records in children older than five.

Methods

Cohort study of 10,811 children born in Navarra (Spain) between 2002 and 2003, who were still living in this region by December 2016. We examined the differences between measured and non-measured children older than 5 years considering weight-associated variables (sex, rural or urban residence, family income and weight status at 2–5 yrs). These variables were used to calculate stabilized weights for inverse-probability weighting and to conduct multiple imputation for the missing data. We calculated complete data prevalence and adjusted prevalence considering the missing data using inverse-probability weighting and multiple imputation for ages 6 to 14 and group ages 6 to 9 and 10 to 14.

Results

For 6–9 years, complete data, inverse-probability weighting and multiple imputation obesity age-adjusted prevalence were 13.18% (95% CI: 12.54–13.85), 13.22% (95% CI: 12.57–13.89) and 13.02% (95% CI: 12.38–13.66) and for 10–14 years 8.61% (95% CI: 8.06–9.18), 8.62% (95% CI: 8.06–9.20) and 8.24% (95% CI: 7.70–8.78), respectively.

Conclusions

Ages at which well-child visits are scheduled and for the 6 to 9 and 10 to 14 age groups, weight status estimations are similar using complete data, multiple imputation and inverse-probability weighting. Readily available electronic health record data may be a tool to monitor the weight status in children.

Achievement of cardiovascular risk factor targets according to sex and previous history of cardiovascular disease in type 2 diabetes: A population-based study

AIMS

The main objective was to assess, using real-practice primary care records, the degree of control of cardiovascular risk factor targets. Records were stratified by the presence of previous history or cardiovascular disease (CVD), and sex differences in the fulfillment profile were analyzed.

METHODS

This is a cross-sectional population-based study conducted in Spain. Type 2 diabetes patients over 20 years old (n = 32,638) were identified from primary care electronic health records, and the following information was extracted: glycated hemoglobin (HbA1c), systolic and diastolic blood pressure (SBP and DBP), LDL and HDL cholesterol levels, triglycerides, BMI and smoking history.

RESULTS

Patients with CVD had worse control of HbA1c than patients without it, (HbA1c < 7% 56.9% vs. 61.2%) but better control of BP (<130/80: 43.5% vs 38.2%) and lipids. In the group without prior CVD history, women had worse control of HbA1c, LDL, HDL, BMI and triglycerides and better control of blood pressure and smoking. These differences were maintained or accentuated in the group with previous CVD.

CONCLUSIONS

Women had poorer control of CV risk factors in both groups, and the sex-gap is accentuated in patients with previous CVD.