Ethnic 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，评价非裔美国人、亚洲人、高加索人、菲律宾人和拉丁美洲人的大型、特征明确的人群中糖尿病并发症发生率和前驱因素的种族差异。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。该研究者先前报告了KP糖尿病成员并发症发生率的种族差异结果，但模式不一致，尽管有统一的健康覆盖（附录A）。下一步将是确定因族裔而异的可改变因素，从而可能有助于解释观察到的差异。如果这些风险因素在不同种族群体中的患病率和/或效应大小不同，则它们可以解释部分种族差异和并发症发生率的不一致模式。我们建议调查和前瞻性随访约20，000名糖尿病患者，其中5个最大的种族群体具有相同的代表性，以收集有关潜在解释性，可改变的风险因素（临床，社会经济，行为，心理社会）的丰富信息来源。这些因素可以作为干预措施的适当目标，旨在减少并发症的种族差异。次要目标包括 评估以下方面的种族差异：i）患者-提供者关系质量与患者依从性之间的关联; ii）获得适当专科护理的机会和标准护理流程的比率; iii）较小的、很少研究的种族群体（美洲原住民、太平洋岛民和南亚人）中并发症的发生率;以及iv）新引入的预防性卫生创新的传播率。次要目标5和6将以1994年发起的一项调查的约78，000名答复者（答复率83%）的一项正在进行的纵向研究中的一个预先存在的队列为基础。通过研究具有统一医疗保险的人群，这项研究将补充现有的国家监测和基于人群的研究，包括具有不同医疗保险水平的患者。这些后者的研究是不太能够解开的混杂效应的种族差异在医疗保健的获得和质量。进一步描述当代糖尿病投保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措施重点的关键可变因素，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.