Educational Disparities in Diabetes Complications

描述（由申请人提供）：本提案的广泛、长期目标是在Kaiser Permanente（KP）综合管理式护理环境中，在大量特征明确的人群中评价教育在糖尿病并发症发生率中的作用。这项研究将利用1994年开始的约78，000名调查受访者（83%的应答率）的队列，收集他们自我报告的教育程度数据。使用调查日期作为基线，将收集关于中介变量和以下结局的随访数据（长达14年）：事件并发症，包括心肌梗死、卒中、充血性心力衰竭、终末期肾病、下肢截肢、增殖性视网膜病、急性代谢事件、成本和死亡。第二，将在大约15，000名年龄在50-75岁的2型糖尿病患者的分层随机样本中进行新的调查，其中非洲裔美国人、高加索人和拉丁美洲人的代表性相等。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。主要目的包括与其他RFA受赠方合作，评估不同的教育措施;估计并发症的教育梯度;评估介导教育梯度的可修改因素（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介导的影响。次要目的包括评估以下内容：种族差异的教育梯度;关于障碍的看法，以照顾;教育的影响，病人提供者的关系和坚持;是否转介到专科护理的比率不同的教育程度;和教育差异的医疗保健费用。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，未充分利用专科护理，但并发症发生率较高，更有可能住院或在急诊室就诊，并产生更大的医疗保健费用。本研究人群的统一健康覆盖避免了基于人群的样本常见的残留混杂，这些样本通常因医疗保健获得和/或质量差异的调整不足而受到影响。在教育和并发症之间起中介作用的可变因素构成了旨在减少教育差距的干预措施的候选目标。关注糖尿病并发症是特别令人信服的，因为观察到在医疗保健费用方面存在很大的教育差异，并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.