Educational Disparities in Diabetes Complications

描述（由申请人提供）：本提案的广泛、长期目标是评估教育在糖尿病并发症发生率中的作用，在一个大的、特征明确的人群中，在一个综合的、管理的医疗环境中Kaiser Permanente （KP）。本研究将利用1994年开始的约78,000名调查受访者（83%的回复率）的队列，收集他们自我报告的教育程度数据。以调查日期为基线，随访数据（长达14年）将收集有关中介变量和以下结果的数据：事件并发症，包括心肌梗死、中风、充血性心力衰竭、终末期肾病、下肢截肢、增生性视网膜病变、急性代谢事件、费用和死亡。其次，一项新的调查将在大约5000名年龄在50-75岁之间的2型糖尿病患者中进行分层随机抽样，其中非裔美国人、白种人和拉丁美洲人的比例相等。这项新的调查将提供丰富的教育数据来源和潜在的可修改因素，解释教育和糖尿病并发症之间的联系。主要目标包括与其他区域自由基金受助人合作，评估不同的教育措施；并发症的教育梯度估计；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、社会心理因素）；并区分教育的直接影响和那些通过收入中介的影响。次要目标包括评估以下内容：教育梯度中的种族差异；对护理障碍的看法；教育对医患关系和依从性的影响；转介到专科护理的比率是否因教育程度而异；以及医疗费用的教育差异。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，专科护理利用不足，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。在本研究人群中，统一的健康覆盖避免了基于人群的样本中常见的残留混淆，这些样本往往对医疗保健可及性和/或质量的差异调整不足。调节教育和并发症之间途径的可修改因素为旨在减少教育差异的干预措施提供了候选目标。鉴于观察到医疗保健成本存在巨大的教育差异，以及存在有效的干预措施来改变行为和临床风险因素，对糖尿病并发症的关注尤其引人注目。

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.