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

Ethnic differences in the association between age at diagnosis of diabetes and the risk of cardiovascular complications: a population-based cohort study

BACKGROUND

We examined ethnic differences in the association between age at diagnosis of diabetes and the risk of cardiovascular complications.

METHODS

We conducted a population-based cohort study in Ontario, Canada among individuals with diabetes and matched individuals without diabetes (2002-18). We fit Cox proportional hazards models to determine the associations of age at diagnosis and ethnicity (Chinese, South Asian, general population) with cardiovascular complications. We tested for an interaction between age at diagnosis and ethnicity.

RESULTS

There were 453,433 individuals with diabetes (49.7% women) and 453,433 matches. There was a significant interaction between age at diagnosis and ethnicity (P < 0.0001). Young-onset diabetes (age at diagnosis < 40) was associated with higher cardiovascular risk [hazard ratios: Chinese 4.25 (3.05-5.91), South Asian: 3.82 (3.19-4.57), General: 3.46 (3.26-3.66)] than usual-onset diabetes [age at diagnosis ≥ 40 years; Chinese: 2.22 (2.04-2.66), South Asian: 2.43 (2.22-2.66), General: 1.83 (1.81-1.86)] versus ethnicity-matched individuals. Among those with young-onset diabetes, Chinese ethnicity was associated with lower overall cardiovascular [0.44 (0.32-0.61)] but similar stroke risks versus the general population; while South Asian ethnicity was associated with lower overall cardiovascular [0.75 (0.64-0.89)] but similar coronary artery disease risks versus the general population. In usual-onset diabetes, Chinese ethnicity was associated with lower cardiovascular risk [0.44 (0.42-0.46)], while South Asian ethnicity was associated with lower cardiovascular [0.90 (0.86-0.95)] and higher coronary artery disease [1.08 (1.01-1.15)] risks versus the general population.

CONCLUSIONS

There are important ethnic differences in the association between age at diagnosis and risk of cardiovascular complications.

eHealth Literacy in a Sample of South Asian Adults in Edmonton, Alberta, Canada: Subanalysis of a 2014 Community-Based Survey

BACKGROUND

Digital health interventions are efficient and flexible methods for enhancing the prevention and management of cardiovascular disease and type 2 diabetes. However, little is known about the characteristics associated with eHealth literacy in the Canadian South Asian population.

OBJECTIVE

The aim of this study is to describe perceived eHealth literacy and explore the extent to which it is associated with sociodemographic, health status, and technology use variables in a subset of South Asian Canadians.

METHODS

We analyzed data from the e-Patient Project survey, a mixed-mode cross-sectional survey that occurred in 2014. The eHealth Literacy Scale (eHEALS) was used to measure eHealth literacy in a convenience sample of 511 English- or Punjabi-speaking South Asian adults recruited from a community pharmacy, a family physician office, and community events in Edmonton, Alberta. Multivariable quantile regression was used to explore variables associated with eHealth literacy.

RESULTS

The analysis was restricted to 301 internet users (mean age 39.9, SD 14.8 years; 166/301, 55.1% female) who provided responses to all 8 eHEALS questions and complete demographic information. The mean overall eHEALS score was 29.3 (SD 6.8) out of 40, and 71.4% (215/301) agreed to at least 5 out of the 8 eHEALS items. The eHEALS item with the lowest level of agreement was "I can tell high-quality health resources from low-quality health resources on the internet" (182/301, 60.5%). Although there were statistically significant differences in eHEALS scores according to age, educational achievement, language preference, and the presence of chronic medical conditions, multivariable regression analysis indicated that language preference was the only variable independently associated with eHealth literacy (coefficient -6.0, 95% CI -9.61 to -2.39).

CONCLUSIONS

In our sample of South Asian Canadian internet users, preference for written health information in languages other than English was associated with lower eHealth literacy. Opportunities exist to improve eHealth literacy using culturally and linguistically tailored interventions.

Prevalence and Predictors of Health-Related Internet and Digital Device Use in a Sample of South Asian Adults in Edmonton, Alberta, Canada: Results From a 2014 Community-Based Survey

Background

South Asian Canadians are at high risk of developing cardiovascular disease and diabetes. Consumer-oriented health information technology may help mitigate lifestyle risk factors and improve chronic disease self-management.

Objective

This study aims to explore the prevalence, patterns, and predictors of the use of the internet, digital devices, and apps for health purposes as well as preferences for future use of eHealth support in South Asian Canadians.

Methods

We conducted a cross-sectional, mixed-mode survey in a convenience sample of 831 South Asian adults recruited at faith-based gathering places, health care settings, and community events in Edmonton, Alberta, in 2014. The 706 responders (mean age 47.1, SD 17.6 years; n=356, 50.4% female; n=509, 72.1% Sikh) who provided complete sociodemographic information were included in the analysis, and the denominators varied based on the completeness of responses to each question. Multivariate logistic regression was used to determine sociodemographic and health status predictors of internet use, being a web-based health information seeker, smartphone or tablet ownership, health app use, and willingness to use various modes of eHealth support.

Results

Of all respondents, 74.6% (527/706) were internet users and 47.8% (336/703) were web-based health information seekers. In addition, 74.9% (527/704) of respondents owned a smartphone or tablet and 30.7% (159/518) of these had a health and fitness app. Most internet users (441/527, 83.7%) expressed interest in using ≥1 mode of eHealth support. Older age, being female, having less than high school education, preferring written health information in languages other than English, and lacking confidence in completing medical forms predicted lack of internet use. Among internet users, factors that predicted web-based health information seeking were being female, use of the internet several times per day, being confident in completing medical forms, and preferring health information in English. Predictors of not owning a smartphone or tablet were being older, preferring health information in languages other than English, having less than high school education, living in Canada for <5 years, having a chronic health condition, and having diabetes. Increasing age was associated with lower odds of having a health app. Preferring health information in languages other than English consistently predicted lower interest in all modes of eHealth support.

Conclusions

eHealth-based chronic disease prevention and management interventions are feasible for South Asian adults, but digital divides exist according to language preference, education, age, sex, confidence in completing medical forms, and number of years lived in Canada. Community-based, culturally tailored strategies targeting these factors are required to address existing divides and increase the uptake of credible web-based and app-based resources for health purposes.

Equity of primary care service delivery for low income "sicker" adults across 10 OECD countries

Background

Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally.

Methods

The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent.

Results

Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands.

Conclusion

Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0892-z) contains supplementary material, which is available to authorized users.

Inadequate screening for retinopathy among recent immigrants with type 2 diabetes despite universal health care: A population-based study

AIMS

To examine retinopathy screening and treatment rates for recent immigrants compared to non-immigrants in a universal health care system.

METHODS

Linked health care and immigration databases were used to identify all 771,564 adults diagnosed with diabetes between 1996 and 2007, in Ontario, Canada. The cohort was stratified by their immigration status and followed until 2013 for retinopathy screening and treatment visits.

RESULTS

Retinopathy screening rates were low, and recent immigrants were considerably less likely to receive screening than long-term residents (≥1 examination within 1year: 37.5% vs. 50.5%, adjusted OR 0.76 [95% CI, 0.75-0.77]; ≥3 examinations within 6years: 46.6% vs. 61.9%, adjusted OR 0.77 [95% Cl, 0.76-0.79]). Immigrants were also less likely to receive surgical treatment for retinopathy, but adjustment for the frequency of screening attenuated these differences.

CONCLUSIONS

Despite universal access to physician services, only half of all individuals with newly-diagnosed type 2 diabetes received retinopathy screening within the first year, and recent immigrants were markedly less likely to be screened. After adjusting for screening rates, gaps in surgical treatment for retinopathy were attenuated, suggesting that treatable retinopathy may be being missed among recent immigrants because of inadequate screening.

Improving management of type 2 diabetes in South Asian patients: a systematic review of intervention studies

OBJECTIVES

Optimal control of type 2 diabetes is challenging in many patient populations including in South Asian patients. We systematically reviewed studies on the effect of diabetes management interventions targeted at South Asian patients with type 2 diabetes on glycaemic control.

DESIGN

Systematic review of MEDLINE, EMBASE and CINAHL databases for randomised controlled trials (RCTs) and pre-post-test studies (January 1990 to February 2014). Studies were stratified by where interventions were conducted (South Asia vs Western countries).

PARTICIPANTS

Patients originating from Pakistan, Bangladesh or India with type 2 diabetes.

PRIMARY OUTCOME

Change in glycated haemoglobin (HbA1c). Secondary end points included change in blood pressure, lipid levels, anthropomorphics and knowledge.

RESULTS

23 studies (15 RCTs) met criteria for analysis with 7 from Western countries (n=2532) and 16 from South Asia (n=1081). Interventions in Western countries included translated diabetes education, additional clinical care, written materials, visual aids, and bilingual community-based peers and/or health professionals. Interventions conducted in South Asia included yoga, meditation or exercise, community-based peers, health professionals and dietary education (cooking exercises). Among RCTs in India (5 trials; n=390), 4 demonstrated significant reductions in HbA1c in the intervention group compared with usual care (yoga and exercise interventions). Among the 4 RCTs conducted in Europe (n=2161), only 1 study, an education intervention of 113 patients, reported a significant reduction in HbA1c with the intervention. Lipids, blood pressure and knowledge improved in both groups with studies from India more often reporting reductions in body mass index and waist circumference.

CONCLUSIONS

Overall, there was little improvement in HbA1c level in diabetes management interventions targeted at South Asians living in Europe compared with usual care, although other outcomes did improve. The smaller studies in India demonstrated significant improvements in glycaemic and other end points. Novel strategies are needed to improve glycaemic control in South Asians living outside of India.

Variation in the use of primary care services for diabetes management according to country of birth and geography among older Australians

AIMS

To investigate variation according to country of birth and geography in the use of primary care services funded through Medicare Australia-Australian universal health insurance-for diabetes annual cycle of care among older overseas-born Australians with type-2 diabetes.

METHODS

Records of Medicare claims for medical services were linked to self-administered questionnaire data for people with type-2 diabetes enrolled in the 45 and Up Study, including 840 participants born in Italy, Greece, Vietnam, Lebanon, China, India, or the Philippines and 12,444 participants born in Australia, living in 195 statistical local areas (SLAs) in New South Wales, Australia. Study outcomes included ≥6 claims for general practitioner (GP) visits, at least one claim for specialist, optometrist, Practice Incentive Payment for completion of diabetes annual cycle of care (PIP), GP Management Plan or Team Care Arrangement (GPMP/TCA), allied health, blood tests for glycosylated haemoglobin (HbA1c) and cholesterol, and urine test for micro-albumin. Multivariable multilevel logistic regression was performed, controlling for personal socio-demographic and health characteristics and geographical area remoteness and socio-economic status.

RESULTS

Compared with Australia-born participants, people born in Vietnam and China had significantly lower rates of claims for allied health services (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.05-0.43, and OR 0.40, 95%CI 0.18-0.87, respectively), those born in Italy had lower rates of PIP claims (OR 0.60, 95%CI 0.39-0.92) and micro-albuminuria testings (OR 0.65, 95%CI 0.47-0.89), and those born in the Philippines had lower claims for specialist services (OR 0.59, 95%CI 0.38-0.91). Participants born in Greece and China (GP visits), Vietnam (optometrist services), and India (micro-albuminuria tests) were more likely to claims for these services than Australia-born people. Significant geographic variation was observed for all study outcomes, with the greatest variations in claims for allied health services (variation 9.3%, median odds ratio [MOR] 1.74, 95% credible interval [CrI] 1.60-2.01), PIP (7.8%, MOR 1.65, 95%CrI 1.55-1.83), and GPMP/TCA items (6.6%, MOR 1.58, 95%CrI 1.49-1.73).

CONCLUSIONS

Different approach among geographical areas and intervention programs for identified cultural groups and their providers are warranted to improve disparities in diabetes care.

Family physician ethnicity influences quality of diabetes care for Chinese but not South Asian patients

AIMS

To determine whether sharing the same ethnicity as their family physician influenced the quality of diabetes care for Chinese and South Asian patients in Ontario, Canada.

METHODS

We conducted two related studies: a population-based cohort study of Chinese and South Asian patients with incident diabetes using health care administrative data (n=49,484), and a cross-sectional study of Chinese and South Asian patients with established diabetes using data collected directly from their family physicians' clinical records (n=416). In both studies, quality of care measures were compared between patients whose family physicians were or were not from the same ethnic group.

RESULTS

In the cohort study, Chinese patients whose family physicians were also Chinese were more likely to have a diabetes-related family physician visit and appropriate HbA1c and cholesterol testing. In the cross-sectional study, they were more likely to have foot examinations, to have microalbuminuria testing, and to achieve recommended treatment targets for HbA1c and for LDL-cholesterol. In contrast, for South Asian patients, most quality measures in either study did not differ by physician ethnicity.

CONCLUSIONS

Having a family physician from the same ethnic group was associated with better quality of diabetes care for Chinese but not for South Asian patients.

Barriers and Facilitators for Type-2 Diabetes Management in South Asians: A Systematic Review

Objective

Although South Asian populations have among the highest burden of type 2 diabetes in the world, their diabetes management remains poor. We systematically reviewed studies on South Asian patient’s perspectives on the barriers and facilitators to diabetes management.

Methods

We conducted a literature search using OVID, CINHAL and EMBASE (January, 1990 –February, 2014) evaluating the core components of diabetes management: interactions with health care providers, diet, exercise, and medication adherence. South Asian patients were self-reported as Indian, Pakistani, Malaysian-Indian or Bangladeshi origin. From 208 abstracts reviewed, 20 studies were included (19 qualitative including mixed methods studies, 1 questionnaire). Barriers and facilitators were extracted and combined using qualitative synthesis.

Results

All studies included barriers and few facilitators were identified. Language and communication discordance with the healthcare provider was a significant barrier to receiving and understanding diabetes education. There was inconsistent willingness to partake in self-management with preference for following their physician’s guidance. Barriers to adopting a diabetic diet were lack of specific details on South Asian tailored diabetic diet; social responsibilities to continue with a traditional diet, and misconceptions on the components of the diabetic diet. For exercise, South Asian patients were concerned with lack of gender specific exercise facilities and fear of injury or worsening health with exercise. Patients reported a lack of understanding about diabetes medication management, preference for folk and phytotherapy, and concerns about the long-term safety of diabetes medications. Facilitators included trust in care providers, use of culturally appropriate exercise and dietary advice and increasing family involvement. Overall themes for the barriers included lack of knowledge and misperceptions as well as lack of cultural adaptation to diabetes management.

Conclusion

Diabetes programs that focus on improving communication, addressing prevailing misconceptions, and culture specific strategies may be useful for improving diabetes management for South Asians.

Utilization of health resources in South Asian, Chinese and white patients with diabetes mellitus

AIMS

We sought to determine whether there are differences in health resource utilization among South Asian (SA), Chinese and White patients with newly diagnosed diabetes mellitus.

METHODS

We used province-wide administrative data from British Columbia, Canada (1997-2006) to determine proportion of patients with ≥2 visits/year for all outpatient and family physician (FP) visits, proportion of patients with at least one annual visit to specialists, ophthalmology/optometry and hospital admissions by ethnic group.

RESULTS

There were 9529 South Asian, 14,084 Chinese and 143,630 White patients with newly diagnosed diabetes in the study. Over 90% of each of the ethnic groups visited their FP ≥2 visits/year. Chinese patients were less likely to visit FP, ophthalmology/optometrists and specialists compared to White patients. SA patients had fewer ophthalmology/optometry visits compared to White populations. White patients had higher rates of hospitalization.

CONCLUSION

Although all groups had high proportion of patients with appropriate frequency of FP visits, other aspects of health care utilization varied significantly by ethnicity.

Cardiovascular complications and mortality after diabetes diagnosis for South Asian and Chinese patients: a population-based cohort study

OBJECTIVE

Many non-European ethnic groups have an increased risk for diabetes; however, the published literature demonstrates considerable uncertainty about the rates of diabetes complications among minority populations. The objective of this study was to determine the risks of cardiovascular complications and of mortality after diabetes diagnosis for South Asian and Chinese patients, compared with European patients.

RESEARCH DESIGN AND METHODS

A population-based cohort study identified all 491,243 adults with newly diagnosed diabetes in Ontario, Canada, between April 2002 and March 2009. Subjects were followed until March 2011 for the first occurrence of any cardiovascular complication of diabetes (coronary artery disease, stroke, or lower-extremity amputation) and for all-cause mortality. Median follow-up was 4.7 years.

RESULTS

The crude incidence of cardiovascular complications after diabetes diagnosis was 17.9 per 1,000 patient-years among European patients, 12.0 among South Asian patients, and 7.7 among Chinese patients. After adjusting for baseline characteristics, the cause-specific hazard ratios (HRs) for cardiovascular complications relative to European patients were 0.95 (95% CI 0.90-1.00; P = 0.056) and 0.50 (0.46-0.53; P < 0.001) for South Asian and Chinese patients, respectively. Mortality was lower for both minority groups (adjusted HR for South Asian patients 0.56 [95% CI 0.52-0.60]; P < 0.001; for Chinese patients 0.58 [0.55-0.62]; P < 0.001).

CONCLUSIONS

Chinese patients were at substantially lower risk than European patients for cardiovascular complications after diabetes diagnosis, whereas South Asian patients were at comparable risk. Mortality after diabetes diagnosis was markedly lower for both minority populations.

Gestational diabetes mellitus and pregnancy outcomes among Chinese and South Asian women in Canada

OBJECTIVE

To determine the association between Chinese or South Asian ethnicity and adverse neonatal and maternal outcomes for women with gestational diabetes compared to the general population.

METHODS

A cohort study was conducted using population-based health care databases in Ontario, Canada. All 35,577 women aged 15-49 with gestational diabetes who had live births between April 2002 and March 2011 were identified. Their delivery hospitalization records and the birth records of their neonates were examined to identify adverse neonatal outcomes and adverse maternal outcomes.

RESULTS

Compared to infants of mothers from the general population (55.5%), infants of Chinese mothers had a lower risk of an adverse outcome at delivery (42.9%, adjusted odds ratio 0.63, 95% confidence interval 0.58-0.68), whereas infants of South Asian mothers had a higher risk (58.9%, adjusted odds ratio 1.15, 95% confidence interval 1.07-1.23). Chinese women also had a lower risk of adverse maternal outcomes (32.4%, adjusted odds ratio 0.58, 95% confidence interval 0.54-0.63) compared to general population women (41.2%), whereas the risk for South Asian women was not different (39.4%, adjusted odds ratio 0.94, 95% confidence interval 0.88-1.02) from that of general population women.

CONCLUSIONS

The risk of complications of gestational diabetes differs significantly between Chinese and South Asian patients and the general population in Ontario. Tailored interventions for gestational diabetes management may be required to improve pregnancy outcomes in high-risk ethnic groups.