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‘Alarming’ rate of diabetes complications at diagnosis in underinsured minority populations
A cohort of predominantly black and Hispanic adults in Chicago had significantly higher rates of diabetes-related complications at the time of disease diagnosis when compared against nationally insured and white cohorts, particularly microvascular complications, according to findings from a cross-sectional study.
“We found that in underinsured, ethnic minority patients with newly diagnosed type 2 diabetes, there is already a much higher prevalence of complications at diagnosis when compared with insured patients with newly diagnosed type 2 diabetes,” Leon Fogelfeld, MD, chief of the division of endocrinology at John H. Stroger Jr. Hospital of Cook County in Chicago and endocrinology fellowship program director at Rush University Medical Center, told Endocrine Today. “These findings are important in view of the changing landscape of health insurance in the USA. If there would be less coverage, especially for minority populations, it may result in a higher rate of complications at the time of diagnosis of diabetes and as the disease is progressing.”
In a retrospective, cross-sectional study, Fogelfeld and colleagues analyzed electronic health records from 2,280 patients newly diagnosed with type 2 diabetes between 2003 and 2013 who were referred to an American Diabetes Association-certified diabetes center in Chicago within 1 year of diagnosis. Within the cohort, 48.1% were black, 32.5% were Hispanic, 69.9% were unemployed and 28.4% were not English speakers. Microvascular and macrovascular complications, as well as hypertension, were documented at presentation. Main outcome was evaluation of diabetes-related complications at the time of clinical diagnosis of diabetes. Secondary outcomes included identification of the demographic and clinical factors associated with the development of complications. Additionally, researchers compared the Chicago cohort with those newly diagnosed with type 2 diabetes in a diverse population in South London, United Kingdom (n = 1,149; National Health Service; years studied, 2012-2013) and insured patients in Portland, Oregon (n = 7,844; 90% white; managed care; years studied, 1996-1998).
In comparing the three cohorts, researchers observed that the Chicago cohort was younger at the time of diagnosis vs. the South London and Portland cohorts (mean age at diagnosis, 49 years, 56 years and 55 years, respectively; P < .001) and had higher HbA1c (mean HbA1c at diagnosis, 10%, 6.6% and 8.2%, respectively; P < .001). Microvascular complications were higher in the Chicago cohort vs. the South London and Portland cohorts, particularly nephropathy (22.2% vs. 16.7% and 5.7%, respectively; P < .001) and retinopathy (10.7% vs. 7.9% and 1.4%, respectively; P < .001).
The researchers found that macrovascular complication rates were similar across cohorts apart from a higher rate of coronary artery disease in the Portland cohort; however, they noted that the difference may be explained by the older age at diagnosis in the Portland cohort.
In the Chicago cohort, the researchers found that both microvascular and macrovascular complications were associated with dyslipidemia (OR = 1.73; 95% CI, 1.3-2.29), being insured (OR = 1.75; 95% CI, 1.16-2.62), hypertension (OR = 1.43; 95% CI, 1.14-1.8), English speaking (OR = 1.35; 95% CI, 1.06-1.72) and older age (OR = 1.02; 95% CI, 1.01-1.03), as well as triglyceride to HDL cholesterol ratio (OR = 1.02; 95% CI, 1.01-1.05).
Reasons for the observed associations between complications and having insurance and speaking English are not clear, the researchers noted.
“In comparison to other cohorts with different ethnic compositions and, above all, with better medical insurance coverage, the Chicago cohort showed an alarming rate of diabetes complications already at the initial diagnosis of diabetes,” the researchers wrote. “The high prevalence of diabetes complications at the initial diagnosis may be a precondition, in this cohort and in other similarly underinsured minority populations, of worse progression of diabetes and its disabling microvascular and macrovascular hard outcomes.”
Fogelfeld said there is a need to encourage and incentivize health systems to put an emphasis on early detection to lower the rate of diabetes complications.
“Real-world outcomes research could identify the best detection methods of for early diagnosis of diabetes,” he said. – by Regina Schaffer
For more information:
Leon Fogelfeld, MD, can be reached at John Stroger Jr. Hospital of Cook County, Division of Endocrinology, 1900 W. Polk St., Room 811, Chicago, IL 60612; email: lfogelfeld@cookcountyhhs.org.
Disclosures: The authors report no relevant financial disclosures.