Ethnic Disparities in Diabetic Complications in an Insured Population

TLDR

Minorities experience higher rates of microvascular complications, often attributed to unequal access to quality health care. The study aimed to assess ethnic disparities in diabetic complication incidence within a nonprofit prepaid health care organization. A longitudinal observational study of 62,432 diabetic patients at Kaiser Permanente (1995–1998) measured MI, stroke, CHF, LEA, and ESRD using hospitalization discharge diagnoses and procedures, and examined ethnic differences after adjusting for demographic, socioeconomic, behavioral, and clinical factors. Adjusted analyses showed blacks, Asians, and Latinos had lower hazard ratios for MI, stroke, CHF, and LEA compared to whites, but higher rates of ESRD (HRs 2.03, 1.85, 1.46), with no significant differences for stroke, CHF, or LEA among blacks and no Latino‑white differences for LEA, indicating persistent disparities likely due to genetic or unme.

Abstract

Higher rates of microvascular complications have been reported for minorities. Disparate access to quality health care is a common explanation for ethnic disparities in diabetic complication rates in the US population. Examining an ethnically diverse population with uniform health care coverage may be useful.To assess ethnic disparities in the incidence of diabetic complications within a nonprofit prepaid health care organization.Longitudinal observational study conducted January 1, 1995, through December 31, 1998, at Kaiser Permanente Medical Care Program in northern California.A total of 62 432 diabetic patients, including Asians (12%), blacks (14%), Latinos (10%), and whites (64%).Incident myocardial infarction (MI), stroke, congestive heart failure (CHF), and nontraumatic lower extremity amputation (LEA), defined by primary hospitalization discharge diagnosis, procedures, or underlying cause of death; and end-stage renal disease (ESRD), defined as renal insufficiency requiring renal replacement therapy or transplantation for survival or by underlying cause of death.Patterns of ethnic differences were not consistent across complications and frequently persisted despite adjustment for a wide range of demographic, socioeconomic, behavioral, and clinical factors. Adjusted hazard ratios (relative to that of whites) were 0.56, 0.68, and 0.68 for blacks, Asians, and Latinos, respectively (P<.001), for MI; 0.76 and 0.72 for Asians and Latinos, respectively (P<.01), for stroke; 0.70 and 0.61 for Asians and Latinos, respectively (P<.01), for CHF; 0.40 for Asians (P<.001) for LEA; and 2.03, 1.85, and 1.46 for blacks, Asians, and Latinos, respectively (P<.01), for ESRD. There were no statistically significant black-white differences for stroke, CHF, or LEA and no Latino-white differences for LEA.This study confirms previous reports of elevated incidence of ESRD among ethnic minorities, despite uniform medical care coverage, and provides new evidence that rates of other complications are similar or lower relative to those of whites. The persistence of ethnic disparities after adjustment suggests a possible genetic origin, the contribution of unmeasured environmental factors, or a combination of these factors.