Ethnic Disparities in Diabetes Complications

描述(由申请人提供)：这项提案的广泛、长期目标是评估在Kaiser Permanente(KP)综合管理护理环境中，非裔美国人、亚洲人、高加索人、菲律宾人和拉美人组成的具有良好特征的庞大人口中糖尿病并发症发生率和先兆的种族差异。这项研究将侧重于糖尿病并发症的卫生服务和流行病学方面，包括心肌梗死、中风、充血性心力衰竭、终末期肾脏疾病、下肢截肢和增殖性视网膜病变。糖尿病并发症的差异是有据可查的。这位调查者先前报告了种族差异的发现，但模式不一致，在KP的糖尿病成员中，尽管医疗覆盖范围相同，但并发症发生率仍存在差异(附录A)。下一步将是确定因族裔而不同的可修改因素，从而有助于解释观察到的差异。如果这些危险因素在不同种族群体中的患病率和/或影响大小不同，它们可能解释了种族差异和并发症发生率不一致模式的一部分。我们建议对大约20,000名糖尿病患者进行调查和前瞻性跟踪，这些患者来自5个最大的种族群体，具有同等代表性，以收集关于潜在的可解释的、可改变的危险因素(临床、社会经济、行为、心理社会)的丰富信息来源。这些因素可作为旨在减少并发症方面族裔差异的干预措施的适当目标。次要目标包括 评估以下方面的种族差异：1)患者-提供者关系的质量与患者依从性之间的联系；2)获得适当的专科护理的机会和标准护理程序的比率；3)较小的、很少被研究的种族群体(美洲原住民、太平洋岛民和南亚人)的并发症发生率；以及4)新引入的预防性卫生创新的扩散比率。次级目标5和6将以先前存在的队列为基础，对1994年发起的一项调查的约78 000名答复者进行持续的纵向研究(答复率为83%)。通过研究具有统一医疗覆盖范围的人群，这项研究将补充现有的国家监测和基于人群的研究，这些研究包括不同医疗覆盖水平的患者。这些后一项研究较难理清卫生保健机会和质量方面的种族差异造成的混乱影响。进一步确定当代有保险的糖尿病人群并发症发生率的种族差异，并确定可作为有针对性干预重点的关键可改变因素，将具有公共卫生和科学价值。

DESCRIPTION (provided by applicant): The broad, long-term objective of this proposal is to evaluate ethnic differences in the incidence and antecedents of diabetic complications in a large, well-characterized population of African Americans, Asians, Caucasians, Filipinos, and Latinos within an integrated, managed care setting Kaiser Permanente (KP). The study will focus on health services and epidemiologic aspects of diabetic complications including myocardial infarction, stroke, congestive heart failure, end-stage renal disease, lower-extremity amputation and proliferative retinopathy. Disparities in the complications of diabetes are well documented. This investigator previously reported findings of ethnic disparities, but with inconsistent patterns, in rates of complications among diabetic members of KP, despite uniform health coverage (Appendix A). The next step will be to identify modifiable factors that differ by ethnicity and may therefore help to explain observed disparities. If such risk factors differ either in prevalence and/or effect size across ethnic groups, they may explain a portion of the ethnic disparities and inconsistent patterns of rates of complications. We propose to survey and prospectively follow approximately 20,000 diabetic patients, with equal representation from the 5 largest ethnic groups, to collect a rich source of information regarding potentially explanatory, modifiable risk factors (clinical, socioeconomic, behavioral, psychosocial). These factors could serve as appropriate targets for interventions aiming to reduce ethnic disparities in complications. Secondary aims include evaluating ethnic differences in i) the association between the quality of the patient-provider relationship and patient adherence; ii) access to appropriate specialty care and rates of standard processes of care; iii) the incidence of complications among smaller, rarely studied ethnic groups (Native Americans, Pacific Islanders and South Asians); and iv) rates of diffusion of newly introduced preventive health innovations. Secondary aims 5 and 6 will be based on a pre-existing cohort in an ongoing longitudinal study of approximately 78,000 respondents to a survey initiated in 1994 (83% response rate). By studying a population with uniform health coverage, this study will complement extant national surveillance and population-based studies that include patients with varying levels of medical coverage. These latter studies are less able to disentangle the confounding effect of ethnic disparities in health care access and quality. Further characterizing ethnic disparities in the incidence of complications in a contemporary, insured population with diabetes and identifying key modifiable factors that can be the focus of targeted interventions will have public health and scientific value.