Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study
Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differe...
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| Veröffentlicht in: | PLoS medicine 2020-05, Vol.17 (5), p.e1003106 |
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| description | Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differences in therapeutic management, the aim of this study was to identify ethnic differences in the timeliness of initiation and intensification of glucose-lowering therapy in individuals newly diagnosed with T2DM in the United Kingdom.
An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012) |
| doi_str_mv | 10.1371/journal.pmed.1003106 |
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An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012); correspondingly, treatment inertia was significantly higher in nonwhite groups at this stage relative to white groups (South Asian OR 2.68, 95% CI 1.89-3.80 p < 0.001; black OR 1.82, 95% CI 1.13-2.79, p = 0.013). At both stages of treatment intensification, nonwhite groups had fewer HbA1c measurements than white groups. Limitations included variable quality and completeness of routinely recorded data and a lack of information on medication adherence.
In this large UK cohort, we found persuasive evidence that South Asian and black groups intensified to noninsulin combination therapy and insulin therapy more slowly than white groups and experienced greater therapeutic inertia following identification of uncontrolled HbA1c. Reasons for delays are multifactorial and may, in part, be related to poorer long-term monitoring of risk factors in nonwhite groups. Initiatives to improve timely and appropriate intensification of diabetes treatment are key to reducing disparities in downstream vascular outcomes in these populations.]]></description><identifier>ISSN: 1549-1676</identifier><identifier>ISSN: 1549-1277</identifier><identifier>EISSN: 1549-1676</identifier><identifier>DOI: 10.1371/journal.pmed.1003106</identifier><identifier>PMID: 32413037</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adolescent ; Adult ; Adults ; Aged ; Analysis ; Biology and life sciences ; Blood Glucose - metabolism ; Blood pressure ; Body mass index ; Cohort analysis ; Cohort Studies ; Cultural differences ; Diabetes ; Diabetes mellitus (non-insulin dependent) ; Diabetes Mellitus, Type 2 - diagnosis ; Diabetes Mellitus, Type 2 - drug therapy ; Diabetes therapy ; Diabetic retinopathy ; Drug therapy ; Electronic health records ; Epidemiology ; Ethnicity ; Female ; Glucose ; Glycated Hemoglobin - analysis ; Glycosylated hemoglobin ; Hemoglobin ; Humans ; Hygiene ; Hypoglycemic agents ; Hypoglycemic Agents - pharmacology ; Insulin ; Kidney diseases ; Male ; Medicine ; Medicine and health sciences ; Middle Aged ; Minority & ethnic groups ; Oral administration ; Overweight ; Patient compliance ; Physical Sciences ; Primary care ; Risk Factors ; Type 2 diabetes ; United Kingdom</subject><ispartof>PLoS medicine, 2020-05, Vol.17 (5), p.e1003106</ispartof><rights>COPYRIGHT 2020 Public Library of Science</rights><rights>2020 Mathur et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2020 Mathur et al 2020 Mathur et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c764t-1f1bf77bdb92a7ee241d553a18a89d9d54c1db5e709a358fcb8371dfd89200963</citedby><cites>FETCH-LOGICAL-c764t-1f1bf77bdb92a7ee241d553a18a89d9d54c1db5e709a358fcb8371dfd89200963</cites><orcidid>0000-0002-1883-8771 ; 0000-0002-3817-8790 ; 0000-0002-6211-2775 ; 0000-0002-8970-1406</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228040/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228040/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,2102,2928,23866,27924,27925,53791,53793,79600,79601</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32413037$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Mauricio, Didac</contributor><creatorcontrib>Mathur, Rohini</creatorcontrib><creatorcontrib>Farmer, Ruth E</creatorcontrib><creatorcontrib>Eastwood, Sophie V</creatorcontrib><creatorcontrib>Chaturvedi, Nish</creatorcontrib><creatorcontrib>Douglas, Ian</creatorcontrib><creatorcontrib>Smeeth, Liam</creatorcontrib><title>Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study</title><title>PLoS medicine</title><addtitle>PLoS Med</addtitle><description><![CDATA[Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differences in therapeutic management, the aim of this study was to identify ethnic differences in the timeliness of initiation and intensification of glucose-lowering therapy in individuals newly diagnosed with T2DM in the United Kingdom.
An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012); correspondingly, treatment inertia was significantly higher in nonwhite groups at this stage relative to white groups (South Asian OR 2.68, 95% CI 1.89-3.80 p < 0.001; black OR 1.82, 95% CI 1.13-2.79, p = 0.013). At both stages of treatment intensification, nonwhite groups had fewer HbA1c measurements than white groups. Limitations included variable quality and completeness of routinely recorded data and a lack of information on medication adherence.
In this large UK cohort, we found persuasive evidence that South Asian and black groups intensified to noninsulin combination therapy and insulin therapy more slowly than white groups and experienced greater therapeutic inertia following identification of uncontrolled HbA1c. Reasons for delays are multifactorial and may, in part, be related to poorer long-term monitoring of risk factors in nonwhite groups. Initiatives to improve timely and appropriate intensification of diabetes treatment are key to reducing disparities in downstream vascular outcomes in these populations.]]></description><subject>Adolescent</subject><subject>Adult</subject><subject>Adults</subject><subject>Aged</subject><subject>Analysis</subject><subject>Biology and life sciences</subject><subject>Blood Glucose - metabolism</subject><subject>Blood pressure</subject><subject>Body mass index</subject><subject>Cohort analysis</subject><subject>Cohort Studies</subject><subject>Cultural differences</subject><subject>Diabetes</subject><subject>Diabetes mellitus (non-insulin dependent)</subject><subject>Diabetes Mellitus, Type 2 - diagnosis</subject><subject>Diabetes Mellitus, Type 2 - drug therapy</subject><subject>Diabetes therapy</subject><subject>Diabetic retinopathy</subject><subject>Drug therapy</subject><subject>Electronic health records</subject><subject>Epidemiology</subject><subject>Ethnicity</subject><subject>Female</subject><subject>Glucose</subject><subject>Glycated Hemoglobin - analysis</subject><subject>Glycosylated hemoglobin</subject><subject>Hemoglobin</subject><subject>Humans</subject><subject>Hygiene</subject><subject>Hypoglycemic agents</subject><subject>Hypoglycemic Agents - pharmacology</subject><subject>Insulin</subject><subject>Kidney diseases</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine and health sciences</subject><subject>Middle Aged</subject><subject>Minority & ethnic groups</subject><subject>Oral administration</subject><subject>Overweight</subject><subject>Patient compliance</subject><subject>Physical Sciences</subject><subject>Primary care</subject><subject>Risk Factors</subject><subject>Type 2 diabetes</subject><subject>United Kingdom</subject><issn>1549-1676</issn><issn>1549-1277</issn><issn>1549-1676</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>DOA</sourceid><recordid>eNqVk-2K1DAUhoso7jp6B6IFQRDsmKRp0_hDGJZVBxcX1PVvSPMxzdBpukmqzk14zWac7jqFEZQGmp4875vknJ4keQzBHOYEvlrbwXW8nfcbJecQgByC8k5yCgtMM1iS8u7B_CR54P0aAEQBBfeTkxxhmIOcnCY_z0PTGZFK43vuTDDKp6aLI055MLZLeSfjZ1CdN9qIfczqKOC1CpEOTvGwUV3Y6bgc2uDT7yY0adj2KkV_wLgcGpVefXiZQkpBhgAkr9NFKmxjXUh9GOT2YXJP89arR-N7lly9Pf9y9j67uHy3PFtcZIKUOGRQw1oTUsuaIk6UiteRRZFzWPGKSioLLKCsC0UA5XlRaVFXMWVSy4oiAGiZz5Kne9--tZ6NqfQMYYRxWeDoNUuWe0Javma9Mxvutsxyw34HrFsx7oIRrWJEEVyXRANFK0wI5gTjmkCs6xJQUaPo9WbcbahjtURMluPtxHS60pmGrew3RhCqAAbR4Nlo4Oz1oHz4y5FHasXjqUynbTQTG-MFW5Q5ogUoKhyp7Ai1Up2KO9tOaRPDE35-hI-PVBsjjgpeTASRCepHWPHBe7b8_Ok_2I__zl5-nbLPD9hG8TY03rbD7u_1UxDvQeGs907p26pAwHZ9dpNptuszNvZZlD05rOit6Kax8l-YNyDX</recordid><startdate>20200515</startdate><enddate>20200515</enddate><creator>Mathur, Rohini</creator><creator>Farmer, Ruth E</creator><creator>Eastwood, Sophie V</creator><creator>Chaturvedi, Nish</creator><creator>Douglas, Ian</creator><creator>Smeeth, Liam</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>IOV</scope><scope>ISN</scope><scope>ISR</scope><scope>3V.</scope><scope>7TK</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>M0S</scope><scope>M1P</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>5PM</scope><scope>DOA</scope><scope>CZK</scope><orcidid>https://orcid.org/0000-0002-1883-8771</orcidid><orcidid>https://orcid.org/0000-0002-3817-8790</orcidid><orcidid>https://orcid.org/0000-0002-6211-2775</orcidid><orcidid>https://orcid.org/0000-0002-8970-1406</orcidid></search><sort><creationdate>20200515</creationdate><title>Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study</title><author>Mathur, Rohini ; Farmer, Ruth E ; Eastwood, Sophie V ; Chaturvedi, Nish ; Douglas, Ian ; Smeeth, Liam</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c764t-1f1bf77bdb92a7ee241d553a18a89d9d54c1db5e709a358fcb8371dfd89200963</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Adolescent</topic><topic>Adult</topic><topic>Adults</topic><topic>Aged</topic><topic>Analysis</topic><topic>Biology and life sciences</topic><topic>Blood Glucose - metabolism</topic><topic>Blood pressure</topic><topic>Body mass index</topic><topic>Cohort analysis</topic><topic>Cohort Studies</topic><topic>Cultural differences</topic><topic>Diabetes</topic><topic>Diabetes mellitus (non-insulin dependent)</topic><topic>Diabetes Mellitus, Type 2 - diagnosis</topic><topic>Diabetes Mellitus, Type 2 - drug therapy</topic><topic>Diabetes therapy</topic><topic>Diabetic retinopathy</topic><topic>Drug therapy</topic><topic>Electronic health records</topic><topic>Epidemiology</topic><topic>Ethnicity</topic><topic>Female</topic><topic>Glucose</topic><topic>Glycated Hemoglobin - analysis</topic><topic>Glycosylated hemoglobin</topic><topic>Hemoglobin</topic><topic>Humans</topic><topic>Hygiene</topic><topic>Hypoglycemic agents</topic><topic>Hypoglycemic Agents - pharmacology</topic><topic>Insulin</topic><topic>Kidney diseases</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine and health sciences</topic><topic>Middle Aged</topic><topic>Minority & ethnic groups</topic><topic>Oral administration</topic><topic>Overweight</topic><topic>Patient compliance</topic><topic>Physical Sciences</topic><topic>Primary care</topic><topic>Risk Factors</topic><topic>Type 2 diabetes</topic><topic>United Kingdom</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Mathur, Rohini</creatorcontrib><creatorcontrib>Farmer, Ruth E</creatorcontrib><creatorcontrib>Eastwood, Sophie V</creatorcontrib><creatorcontrib>Chaturvedi, Nish</creatorcontrib><creatorcontrib>Douglas, Ian</creatorcontrib><creatorcontrib>Smeeth, Liam</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Canada</collection><collection>Gale In Context: Science</collection><collection>ProQuest Central (Corporate)</collection><collection>Neurosciences Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><collection>PLoS Medicine</collection><jtitle>PLoS medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Mathur, Rohini</au><au>Farmer, Ruth E</au><au>Eastwood, Sophie V</au><au>Chaturvedi, Nish</au><au>Douglas, Ian</au><au>Smeeth, Liam</au><au>Mauricio, Didac</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study</atitle><jtitle>PLoS medicine</jtitle><addtitle>PLoS Med</addtitle><date>2020-05-15</date><risdate>2020</risdate><volume>17</volume><issue>5</issue><spage>e1003106</spage><pages>e1003106-</pages><issn>1549-1676</issn><issn>1549-1277</issn><eissn>1549-1676</eissn><abstract><![CDATA[Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differences in therapeutic management, the aim of this study was to identify ethnic differences in the timeliness of initiation and intensification of glucose-lowering therapy in individuals newly diagnosed with T2DM in the United Kingdom.
An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012); correspondingly, treatment inertia was significantly higher in nonwhite groups at this stage relative to white groups (South Asian OR 2.68, 95% CI 1.89-3.80 p < 0.001; black OR 1.82, 95% CI 1.13-2.79, p = 0.013). At both stages of treatment intensification, nonwhite groups had fewer HbA1c measurements than white groups. Limitations included variable quality and completeness of routinely recorded data and a lack of information on medication adherence.
In this large UK cohort, we found persuasive evidence that South Asian and black groups intensified to noninsulin combination therapy and insulin therapy more slowly than white groups and experienced greater therapeutic inertia following identification of uncontrolled HbA1c. Reasons for delays are multifactorial and may, in part, be related to poorer long-term monitoring of risk factors in nonwhite groups. Initiatives to improve timely and appropriate intensification of diabetes treatment are key to reducing disparities in downstream vascular outcomes in these populations.]]></abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>32413037</pmid><doi>10.1371/journal.pmed.1003106</doi><orcidid>https://orcid.org/0000-0002-1883-8771</orcidid><orcidid>https://orcid.org/0000-0002-3817-8790</orcidid><orcidid>https://orcid.org/0000-0002-6211-2775</orcidid><orcidid>https://orcid.org/0000-0002-8970-1406</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1549-1676 |
| ispartof | PLoS medicine, 2020-05, Vol.17 (5), p.e1003106 |
| issn | 1549-1676 1549-1277 1549-1676 |
| language | eng |
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| source | MEDLINE; DOAJ Directory of Open Access Journals; Public Library of Science (PLoS) Journals Open Access; EZB-FREE-00999 freely available EZB journals; PubMed Central |
| subjects | Adolescent Adult Adults Aged Analysis Biology and life sciences Blood Glucose - metabolism Blood pressure Body mass index Cohort analysis Cohort Studies Cultural differences Diabetes Diabetes mellitus (non-insulin dependent) Diabetes Mellitus, Type 2 - diagnosis Diabetes Mellitus, Type 2 - drug therapy Diabetes therapy Diabetic retinopathy Drug therapy Electronic health records Epidemiology Ethnicity Female Glucose Glycated Hemoglobin - analysis Glycosylated hemoglobin Hemoglobin Humans Hygiene Hypoglycemic agents Hypoglycemic Agents - pharmacology Insulin Kidney diseases Male Medicine Medicine and health sciences Middle Aged Minority & ethnic groups Oral administration Overweight Patient compliance Physical Sciences Primary care Risk Factors Type 2 diabetes United Kingdom |
| title | Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study |
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