Skip to main content
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Diabetes Care

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Diabetes Care
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
Original Research

Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions

A cross-sectional study

  1. Riyadh Alshamsan, MSC1,
  2. Azeem Majeed, MD, FRCGP1,
  3. Eszter Panna Vamos, MD, PHD1,
  4. Kamlesh Khunti, MD, PHD2,
  5. Vasa Curcin, MSC, PHD3,
  6. Salman Rawaf, MD, PHD1 and
  7. Christopher Millett, PHD, FFPH1
  1. 1Department of Primary Care and Public Health, Imperial College London, London, U.K.
  2. 2Department of Health Sciences, University of Leicester, Leicester, U.K.
  3. 3Department of Computing, Imperial College London, London, U.K.
  1. Corresponding author: Riyadh Alshamsan, ra105{at}imperial.ac.uk.
Diabetes Care 2011 Mar; 34(3): 655-657. https://doi.org/10.2337/dc10-1606
PreviousNext
  • Article
  • Figures & Tables
  • Info & Metrics
  • PDF
Loading

Abstract

OBJECTIVE To examine ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the U.K.

RESEARCH DESIGN AND METHODS This cross-sectional study examined associations between ethnicity, comorbidity, and intermediate outcomes for mean A1C, total cholesterol, and blood pressure levels in 6,690 diabetes patients in South West London.

RESULTS The presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients, with a mean difference in systolic blood pressure of +1.5, +1.4, and +6.2 mmHg, respectively.

CONCLUSIONS Despite major reforms to improve quality, disparities in blood pressure management have persisted in the U.K., particularly among patients with cardiovascular comorbidities. Policy makers should consider the potential impacts of quality initiatives on high-risk groups.

An increasing number of people with diabetes have comorbid medical conditions (1). These patients can be complex to manage, have a higher risk of additional morbidity and mortality, and represent a growing cost for health systems (1,2).

People from ethnic minorities are more likely to have comorbid medical conditions than whites, and delivering high-quality diabetes management to this high-risk group is particularly important for reducing disparities in health outcomes (3–5). Previous studies suggest that patients with multiple conditions may receive similar or higher quality of care than those with a single condition and may have benefited more from quality improvement strategies (6–9). However, few studies have examined whether these benefits extend to patients with diabetes from minority ethnic groups.

The aim of this study was to examine ethnic disparities in diabetes management among people with and without comorbidity in the U.K.’s National Health Service after a period of sustained investment in quality improvement.

RESEARCH DESIGN AND METHODS

The study was conducted in 29 family practices in Wandsworth, London. We identified all adults (≥18 years) with a diagnosis of diabetes registered in 2007 from their electronic medical record (EMR) using an established method (10). Women with gestational diabetes were excluded. We identified comorbid medical conditions from the EMR and divided these into conditions with concordant (hypertension, heart failure, stroke, atrial fibrillation, coronary heart disease, chronic kidney disease) and discordant management goals (chronic obstructive pulmonary disease, asthma, depression) and calculated the number of comorbidities for each patient. Patients who had conditions with both concordant and discordant management goals were categorized as having a concordant condition. Information on ethnic background was collected from patients during registration or consultations. We assigned a socioeconomic status score to each patient based on his or her practice postcode using the Index of Multiple Deprivation (11).

Our outcome measures were the patients’ last recorded A1C, systolic and diastolic blood pressure, and total cholesterol values in 2007. To examine associations between ethnicity, number of comorbidities, and outcome measures, regression models were fitted with practice as a random effect to allow for clustering of patients in practices. Models were adjusted for age, sex, duration of illness, BMI, and socioeconomic status score. We included an interaction term in each model to examine whether the association between comorbidity and our outcome measures varied between ethnic groups. Statistical analyses were performed using Stata 10.1 software (StataCorp LP, College Station, TX).

RESULTS

We identified 7,542 patients with diabetes in 29 family practices. We excluded 113 patients (1.5%) with implausible or missing values and 739 (9.8%) without a recorded ethnicity, leaving 6,690 patients (50.9% men and 49.1% women). Of these, 42.8% were white, 24.4% were black, and 22.2% were South Asian. Table 1 reports the mean differences in intermediate outcomes by ethnicity and number of comorbidities. An interaction between ethnicity and comorbidity was found for systolic blood pressure (P = 0.03). Because no interactions were found for diastolic blood pressure, A1C, and cholesterol, we only present the main effects.

View this table:
  • View inline
  • View popup
Table 1

Mean difference in intermediate outcomes by ethnicity and number of comorbid conditions

Systolic blood pressure

Compared with white patients without comorbidities, mean systolic blood pressure was higher in white patients with one concordant comorbidity (4.6 mmHg, P < 0.001) but was similar to those with two more concordant and one or more discordant comorbidities (Table 1). Relative to white patients without comorbidities, mean systolic blood pressure was similar among black patients without comorbidities and with one or more discordant condition but was higher among black patients with one (5.9 mmHg, P < 0.001) and two or more concordant comorbid conditions (6.2 mmHg, P < 0.001). Relative to white patients without comorbidity, the mean systolic blood pressure was lower among South Asian patients without comorbidity (−2.3 mmHg, P < 0.05) and with one or more discordant condition but was similar in South Asian patients with concordant comorbid conditions.

Diastolic blood pressure

Mean diastolic blood pressure was higher among black patients (1.3 mmHg, P < 0.001) compared with white or South Asian patients. It was higher among people with one concordant condition and lower in patients with one or more discordant conditions compared with those without comorbidity.

A1C

Compared with white patients, mean A1C was higher among black (0.3%, P < 0.001) and South Asian patients (0.2%, P < 0.001). Patients with concordant comorbid conditions had lower A1C (−0.2%, P < 0.01), and those with discordant conditions had similar mean A1C compared with those without comorbidity.

Cholesterol

South Asian patients had lower mean cholesterol levels (−0.2 mmol/L, P < 0.001) than white or black patients. Patients with concordant comorbid conditions had lower cholesterol levels (−0.3 mmol/L, P < 0.001), and patients with discordant conditions had similar mean cholesterol levels compared with those without comorbidity.

CONCLUSIONS

The U.K. health system provides universal coverage and has implemented major reforms to improve quality in chronic disease management in primary care. However, ethnic disparities in blood pressure management have persisted, particularly among patients with cardiovascular comorbidities. Consistent with previous U.K. research, we found that patients with concordant comorbidity had lower mean A1C and cholesterol levels but higher mean blood pressure levels compared with patients with no comorbidities (9). This finding may be partly explained by the much poorer blood pressure control among black patients with concordant comorbidity. People with diabetes with discordant conditions were not better managed than those without comorbidity. This finding suggests that more frequent contact with health services by itself does not improve the management of diabetes.

Our study has a number of limitations. The cross-sectional design of the study did not allow us to assess the effect of quality improvement initiatives on time trends in disparities in diabetes care. We adjusted our analyses for important key covariates but were unable to adjust for clinic attendance. We could not distinguish between type 1 and 2 diabetes and did not have a patient-level measure of socioeconomic status.

The variations in diabetes management among high-risk patients identified in this study are concerning. This suggests that universal coverage and universal investment in quality initiatives may not be sufficient to address health disparities and that more targeted interventions are required (12,13). Health care planners should consider the needs of ethnic minorities and patients suffering from complex conditions when designing and implementing quality improvement programs and continuously monitor such initiatives.

Acknowledgments

This study represents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation programme (08/1716/209). The Wandsworth Primary Care Research Centre has received funding from the Department of Health. The Department of Primary Care and Public Health at Imperial College London is grateful for support from the NIHR Biomedical Research Centre scheme, the NIHR Collaboration for Leadership in Applied Health Research and Care scheme, and the Imperial Centre for Patient Safety and Service Quality. The study was approved by the Wandsworth Local Research Ethics Committee.

No potential conflicts of interest relevant to this article were reported.

R.A. planned the study, analyzed and interpreted data, and wrote the first draft of the manuscript. A.M. interpreted the findings and reviewed the manuscript for important intellectual content. E.P.V. analyzed data, interpreted the findings, and reviewed and edited the manuscript. K.K., V.C., and S.R. interpreted the findings and reviewed the manuscript for important intellectual content. C.M. planned the study, interpreted the findings, and reviewed and edited the manuscript.

Footnotes

  • The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health.

  • Received August 19, 2010.
  • Accepted December 19, 2010.
  • © 2011 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

References

  1. ↵
    1. Schneider KM,
    2. O’Donnell BE,
    3. Dean D
    . Prevalence of multiple chronic conditions in the United States’ Medicare population. Health Qual Life Outcomes 2009;7:82pmid:19737412
    OpenUrlCrossRefPubMed
  2. ↵
    1. Piette JD,
    2. Kerr EA
    . The impact of comorbid chronic conditions on diabetes care. Diabetes Care 2006;29:725–731pmid:16505540
    OpenUrlFREE Full Text
  3. ↵
    1. Lanting LC,
    2. Joung IM,
    3. Mackenbach JP,
    4. Lamberts SW,
    5. Bootsma AH
    . Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: a review. Diabetes Care 2005;28:2280–2288pmid:16123507
    OpenUrlAbstract/FREE Full Text
    1. Trivedi AN,
    2. Zaslavsky AM,
    3. Schneider EC,
    4. Ayanian JZ
    . Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005;353:692–700pmid:16107622
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Millett C,
    2. Netuveli G,
    3. Saxena S,
    4. Majeed A
    . Impact of pay for performance on ethnic disparities in intermediate outcomes for diabetes: a longitudinal study. Diabetes Care 2009;32:404–409pmid:19073759
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Higashi T,
    2. Wenger NS,
    3. Adams JL,
    4. et al
    . Relationship between number of medical conditions and quality of care. N Engl J Med 2007;356:2496–2504pmid:17568030
    OpenUrlCrossRefPubMedWeb of Science
    1. Halanych JH,
    2. Safford MM,
    3. Keys WC,
    4. et al
    . Burden of comorbid medical conditions and quality of diabetes care. Diabetes Care 2007;30:2999–3004pmid:17717287
    OpenUrlAbstract/FREE Full Text
    1. Millett C,
    2. Gray J,
    3. Bottle A,
    4. Majeed A
    . Ethnic disparities in blood pressure management in patients with hypertension after the introduction of pay for performance. Ann Fam Med 2008;6:490–496pmid:19001300
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Millett C,
    2. Bottle A,
    3. Ng A,
    4. et al
    . Pay for performance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med 2009;102:369–377pmid:19734534
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Gray J,
    2. Orr D,
    3. Majeed A
    . Use of Read codes in diabetes management in a south London primary care group: implications for establishing disease registers. BMJ 2003;326:1130pmid:12763987
    OpenUrlAbstract/FREE Full Text
  8. ↵
    Department of Communities and Local Government. Indices of deprivation [article online], 2007. Available from http://webarchive.nationalarchives.gov.uk/+/communities.gov.uk/communities/neighbourhoodrenewal/deprivation/deprivation07. Accessed 23 September 2010
  9. ↵
    1. Mead N,
    2. Roland M
    . Understanding why some ethnic minority patients evaluate medical care more negatively than white patients: a cross sectional analysis of a routine patient survey in English general practices. BMJ 2009;339:b3450pmid:19762416
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Kai J,
    2. Beavan J,
    3. Faull C,
    4. Dodson L,
    5. Gill P,
    6. Beighton A
    . Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study. PLoS Med 2007;4:e323pmid:18001148
    OpenUrlCrossRefPubMed
PreviousNext
Back to top
Diabetes Care: 34 (3)

In this Issue

March 2011, 34(3)
  • Table of Contents
  • About the Cover
  • Index by Author
Sign up to receive current issue alerts
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Diabetes Care.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions
(Your Name) has forwarded a page to you from Diabetes Care
(Your Name) thought you would like to see this page from the Diabetes Care web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions
Riyadh Alshamsan, Azeem Majeed, Eszter Panna Vamos, Kamlesh Khunti, Vasa Curcin, Salman Rawaf, Christopher Millett
Diabetes Care Mar 2011, 34 (3) 655-657; DOI: 10.2337/dc10-1606

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Add to Selected Citations
Share

Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions
Riyadh Alshamsan, Azeem Majeed, Eszter Panna Vamos, Kamlesh Khunti, Vasa Curcin, Salman Rawaf, Christopher Millett
Diabetes Care Mar 2011, 34 (3) 655-657; DOI: 10.2337/dc10-1606
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • RESEARCH DESIGN AND METHODS
    • RESULTS
    • CONCLUSIONS
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Tables
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

Original Research

  • Risk Factors for Longitudinal Resting Heart Rate and Its Associations With Cardiovascular Outcomes in the DCCT/EDIC Study
  • An Age-Related Exponential Decline in the Risk of Multiple Islet Autoantibody Seroconversion During Childhood
  • Association of Implementation of a Comprehensive Preconception-to-Pregnancy Management Plan With Pregnancy Outcomes Among Chinese Pregnant Women With Type 1 Diabetes: The CARNATION Study
Show more Original Research

Epidemiology/Health Services Research

  • Social Deprivation and Incident Diabetes-Related Foot Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study
  • Productivity Benefits of Preventing Type 2 Diabetes in Australia: A 10-Year Analysis
  • Temporal Trends in Incident Hospitalization for Diabetes-Related Foot Ulcer in Type 2 Diabetes: The Fremantle Diabetes Study
Show more Epidemiology/Health Services Research

Similar Articles

Navigate

  • Current Issue
  • Standards of Care Guidelines
  • Online Ahead of Print
  • Archives
  • Submit
  • Subscribe
  • Email Alerts
  • RSS Feeds

More Information

  • About the Journal
  • Instructions for Authors
  • Journal Policies
  • Reprints and Permissions
  • Advertising
  • Privacy Policy: ADA Journals
  • Copyright Notice/Public Access Policy
  • Contact Us

Other ADA Resources

  • Diabetes
  • Clinical Diabetes
  • Diabetes Spectrum
  • Scientific Sessions Abstracts
  • Standards of Medical Care in Diabetes
  • BMJ Open - Diabetes Research & Care
  • Professional Books
  • Diabetes Forecast

 

  • DiabetesJournals.org
  • Diabetes Core Update
  • ADA's DiabetesPro
  • ADA Member Directory
  • Diabetes.org

© 2021 by the American Diabetes Association. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548.