Educational Disparities in Diabetes Complications

描述(由申请人提供)：这项建议的广泛、长期目标是在一个综合的、有管理的护理环境中，评估教育在糖尿病并发症发生率中的作用，该人群具有良好的特征。这项研究将利用1994年开始的一个队列，大约78,000名调查受访者(回复率为83%)收集了他们自我报告的教育程度数据。以调查日期为基线，将收集关于中介变量和以下结果的随访数据(长达14年)：事件并发症，包括心肌梗死、中风、充血性心力衰竭、终末期肾脏疾病、双腿截肢、增殖性视网膜病变、急性代谢事件、费用和死亡。其次，一项新的调查将在大约5000名L 2型糖尿病患者中进行分层随机抽样，年龄在50-75岁之间，其中非洲裔美国人、高加索人和拉丁美洲人比例均等。这项新的调查将提供关于教育的丰富数据来源，以及解释教育与糖尿病并发症之间联系的潜在可修改因素。主要目标包括与其他RFA受赠者合作，评估不同的教育措施；估计并发症中的教育梯度；评估调节教育梯度的可改变因素(例如，健康行为、糖尿病知识、心理社会因素)；以及区分教育的直接影响和通过收入调节的影响。次级目标包括评估以下方面：教育梯度中的种族差异；对护理障碍的看法；教育对患者-提供者关系和依从性的影响；转诊到专科护理的比率是否因教育程度而不同；以及教育对卫生保健成本的差异。我们的初步研究表明，受教育程度较低的糖尿病患者健康状况较差，自我护理技能较差，专科护理未得到充分利用，但并发症发生率较高，更有可能住院或在急诊室就诊，并产生更高的医疗费用。本研究人群的统一健康覆盖避免了以人口为基础的样本所常见的残留混淆，后者往往对卫生保健获得和/或质量方面的差异进行不充分的调整。调节教育与并发症之间途径的可改变因素构成了旨在缩小教育差距的干预措施的候选目标。对糖尿病并发症的关注尤其令人信服，因为观察到医疗保健成本的教育差异很大，而且存在有效的干预措施来改变行为和临床风险因素。

DESCRIPTION (provided by applicant): The broad, long-term objective of this proposal is to evaluate the role of education in the incidence of diabetic complications, in a large, well-characterized population, within an integrated, managed care setting Kaiser Permanente (KP). This study will take advantage of a cohort begun in 1994 of approximately 78,000 survey respondents (83% response rate) for whom self-reported educational attainment data was collected. Using the survey date as baseline, follow-up data (up to 14 years) will be collected on mediating variables and the following outcomes: incident complications, including myocardial infarction, stroke, congestive heart failure, end-stage renal disease, lower-extremity amputation, proliferative retinopathy, acute metabolic events, costs and death. Second, a new survey will be conducted in a stratified random sample of approximately l 5,000 type 2 diabetic patients, ages 50-75, with equal representation of African American, Caucasian and Latinos. This new survey will provide a rich source of data on education and potentially modifiable factors that explain the link between education and complications of diabetes. Primary aims include collaborating with other RFA grantees to evaluate different measures of education; estimating the educational gradient in complications; evaluating modifiable factors that mediate the educational gradient (e.g., health behaviors, diabetes knowledge, psychosocial factors); and differentiating the direct effects of education from those mediated through income. Secondary aims include evaluating the following: ethnic differences in the educational gradient; perceptions regarding barriers to care; the impact of education on patient-provider relationships and adherence; whether rates of referral to specialty care differ by educational attainment; and educational differences in health care costs. Our preliminary studies showed that less educated diabetic patients were in poorer health, had poorer self-care skills, underutilized specialty care, but had higher complication rates, were more likely to be hospitalized or to be seen in the ER, and incurred greater health care costs. Uniform health coverage in this study population avoids residual confounding common to population-based samples, which often suffer from inadequate adjustment for disparities in health care access and/or quality. Modifiable factors that mediate the pathway between education and complications pose candidate targets for interventions aiming to reduce educational disparities. A focus on diabetic complications is particularly compelling given observations of a substantial education differential in health care costs and the existence of efficacious interventions for modifying behavioral and clinical risk factors.