Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990–2017: A cohort study


Autoři: Rohini Mathur aff001;  Ruth E. Farmer aff001;  Sophie V. Eastwood aff002;  Nish Chaturvedi aff002;  Ian Douglas aff001;  Liam Smeeth aff001
Působiště autorů: Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom aff001;  Institute of Cardiovascular Sciences, University College London, London, United Kingdom aff002
Vyšlo v časopise: Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990–2017: A cohort study. PLoS Med 17(5): e32767. doi:10.1371/journal.pmed.1003106
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003106

Souhrn

Background

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.

Methods and findings

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.

Conclusions

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.

Klíčová slova:

Diabetes diagnosis and management – Diabetes mellitus – Drug therapy – Ethnic epidemiology – HbA1c – Inertia – Insulin – Type 2 diabetes


Zdroje

1. World Health Organization. Global report on Diabetes. Geneva: World Health Organization; 2016 [cited 2018 Feb 10]. Available from: https://www.who.int/diabetes/global-report/en/. doi: 10.2337/db15-0956

2. Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Lancet. 2017;389: 2239–2251. doi: 10.1016/S0140-6736(17)30058-2 28190580

3. Diabetes UK. Tackling the crisis: Transforming diabetes care for a better future. Diabetes UK; 2019.

4. Davis TME. Ethnic diversity in Type 2 diabetes. Diabet Med. 2008;25: 52–56. doi: 10.1111/j.1464-5491.2008.02499.x 18717980

5. Malik MO, Govan L, Petrie JR, Ghouri N, Leese G, Fischbacher C, et al. Ethnicity and risk of cardiovascular disease (CVD): 4.8 year follow-up of patients with type 2 diabetes living in Scotland. Diabetologia. 2015;58: 716–725. doi: 10.1007/s00125-015-3492-0 25669630

6. Mathur R, Bhaskaran K, Edwards E, Lee H, Chaturvedi N, Smeeth L, et al. Population trends in the 10-year incidence and prevalence of diabetic retinopathy in the UK: a cohort study in the Clinical Practice Research Datalink 2004–2014. BMJ Open. 2017;7: e014444. doi: 10.1136/bmjopen-2016-014444 28246144

7. Bhopal RS. A four-stage model explaining the higher risk of Type 2 diabetes mellitus in South Asians compared with European populations. Diabet Med. 2013;30: 35–42. doi: 10.1111/dme.12016 22998210

8. Jungmann E, Jungmann G. The influence of hypertension, obesity and metabolic control on microalbuminuria in non-insulin treated patients with type 2 diabetes mellitus. Journal fur Hypertonie. Germany: Krause und Pachernegg GmbH; 1999. pp. 21–26.

9. Bellary S, O’Hare JP, Raymond NT, Mughal S, Hanif WM, Jones A, et al. Premature cardiovascular events and mortality in south Asians with type 2 diabetes in the United Kingdom Asian Diabetes Study—effect of ethnicity on risk. Curr Med Res Opin. 2010;26: 1873–9. doi: 10.1185/03007995.2010.490468 20528107

10. Wilkinson E, Waqar M, Sinclair A, Randhawa G. Meeting the Challenge of Diabetes in Ageing and Diverse Populations: A Review of the Literature from the UK. J Diabetes Res. 2016. doi: 10.1155/2016/8030627 27830158

11. Tillin T, Hughes AD, Mayet J, Whincup P, Sattar N, Forouhi NG, et al. The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians, and African Caribbeans: SABRE (Southall and Brent Revisited)—A prospective population-based study. J Am Coll Cardiol. 2013;61: 1777–86. doi: 10.1016/j.jacc.2012.12.046 23500273

12. Terry T, Raravikar K, Chokrungvaranon N, Reaven PD. Does aggressive glycemic control benefit macrovascular and microvascular disease in type 2 diabetes?: Insights from ACCORD, ADVANCE, and VADT. Curr Cardiol Rep. 2012;14: 79–88. doi: 10.1007/s11886-011-0238-6 22160862

13. Brown A, Reynolds LR, Bruemmer D. Intensive glycemic control and cardiovascular disease: an update. Nat Rev Cardiol. 2010;7: 369–75. doi: 10.1038/nrcardio.2010.35 20404853

14. The National Institute for Health and Care Excellence. Type 2 diabetes in adults: management NICE guidelines [NG28]. London: NICE; 2015 Dec 14. Available from: http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2.

15. Health and Social Care Information Centre. National Diabetes Audit Report 1: Care Processes and Treatment Targets. Health and Social Care Information Centre; 2012 [cited 2016 Jun 30]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/national-diabetes-audit-2012-2013-report-1-care-processes-and-treatment-targets.

16. Bain SC, Bekker Hansen B, Hunt B, Chubb B, Valentine WJ. Evaluating the burden of poor glycemic control associated with therapeutic inertia in patients with type 2 diabetes in the UK. J Med Econ. 2019. doi: 10.1080/13696998.2019.1645018 31311364

17. Herrett E, Gallagher AM, Bhaskaran K, Forbes H, Mathur R, van Staa T, et al. Data Resource Profile: Clinical Practice Research Datalink (CPRD). Int J Epidemiol. 2015 [cited 2015 Jun 7]. doi: 10.1093/ije/dyv098 26050254

18. Eastwood SV, Mathur R, Atkinson M, Brophy S, Sudlow C, Flaig R, et al. Algorithms for the capture and adjudication of prevalent and incident diabetes in UK Biobank. PLoS ONE. 2016. doi: 10.1371/journal.pone.0162388 27631769

19. Mathur R, Bhaskaran K, Chaturvedi N, Leon DA, vanStaa T, Grundy E, et al. Completeness and usability of ethnicity data in UK-based primary care and hospital databases. J Public Health (Oxf). 2014;36. doi: 10.1093/pubmed/fdt116 24323951

20. Index of Multiple Deprivation. English indices of deprivation 2015. Minist Housing, Communities Local Gov; 2015 [cited 2016 Sep 25]. Available from https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015.

21. World Health Organization. Public health Appropriate body mass index for Asian populations and its implications for policy and intervention strategies. Public Health. 2004;363: 157–163. doi: 10.1016/S0140-6736(03)15268-3

22. Khunti K, Gomes MB, Pocock S, Shestakova M V., Pintat S, Fenici P, et al. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes, Obes Metab. 2018;20: 427–437. doi: 10.1111/dom.13088 28834075

23. Mata-Cases M, Franch-Nadal J, Real J, Gratacòs M, López-Simarro F, Khunti K, et al. Therapeutic inertia in patients treated with two or more antidiabetics in primary care: Factors predicting intensification of treatment. Diabetes, Obes Metab. 2018;20: 103–112. doi: 10.1111/dom.13045 28656746

24. Khunti K, Nikolajsen A, Thorsted BL, Andersen M, Davies MJ, Paul SK. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes, Obes Metab. 2016. doi: 10.1111/dom.12626 26743666

25. Bartlett JW, Harel O, Carpenter JR. Asymptotically Unbiased Estimation of Exposure Odds Ratios in Complete Records Logistic Regression. Am J Epidemiol. 2014. doi: 10.1093/aje/kwv114 26429998

26. Russell-Jones D, Pouwer F, Khunti K. Identification of barriers to insulin therapy and approaches to overcoming them. Diabetes, Obes Metab. 2018;20: 488–496. doi: 10.1111/dom.13132 29053215

27. Farmer R, Mathur R, Bhaskaran K, Eastwood S V., Chaturvedi N, Smeeth L. Promises and pitfalls of electronic health record analysis. Diabetologia. 2017. doi: 10.1007/s00125-017-4518-6 29247363

28. Rubino A, McQuay LJ, Gough SC, Kvasz M, Tennis P. Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents in patients with Type 2 diabetes: A population-based analysis in the UK. Diabet Med. 2007. doi: 10.1111/j.1464-5491.2007.02279.x 18042083

29. Kontopantelis E, Reeves D, Valderas JM, Campbell S, Doran T. Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study. BMJ Qual Saf. 2013;22: 53–64. doi: 10.1136/bmjqs-2012-001033 22918988

30. Mathur R, Grundy E, Smeeth L. Availability and use of UK based ethnicity data for health research. Natl Cent Res Methods Work Pap Ser. 2013 Mar. Report No.: 01/13. Available from: http://eprints.ncrm.ac.uk/3040/1/Mathur-_Availability_and_use_of_UK_based_ethnicity_data_for_health_res_1.pdf.

31. Choudhury S, Hussain S, Yao G, Hill J, Malik W, Taheri S. The impact of a diabetes local enhanced service on quality outcome framework diabetes outcomes. PLoS ONE. 2013;8: 8–14. doi: 10.1371/journal.pone.0083738 24358306

32. Khunti K, Ganguli S. Who looks after people with diabetes: Primary or secondary care? J R Soc Med. 2000;93: 183–186. doi: 10.1177/014107680009300407 10844883

33. NHS Commissioning Assembly. The Diabetes Sample Service Specification. NHS Commissioning Assembly; 2014. Available from: https://www.diabetes.org.uk/Professionals/Position-statements-reports/Integrated-diabetes-care.

34. Mathur R, Palla L, Chaturvedi N, Smeeth L. Ethnic differences in the severity and clinical management of type 2 diabetes at time of diagnosis: A cohort study in the Clinical Practice Research Datalink. Diabetes Res Clin Pract. 2020;160: 108006. doi: 10.1016/j.diabres.2020.108006 31923438

35. Khunti S, Khunti K, Seidu S. Therapeutic inertia in type 2 diabetes: prevalence, causes, consequences and methods to overcome inertia. Ther Adv Endocrinol Metab. 2019. doi: 10.1177/2042018819844694 31105931

36. Khunti K, Millar-Jones D. Clinical inertia to insulin initiation and intensification in the UK: A focused literature review. Prim Care Diabetes. 2017;11: 3–12. doi: 10.1016/j.pcd.2016.09.003 27727005

37. Visram H. Patient Barriers to Insulin Use in Multi-Ethnic Populations. Can J Diabetes. 2013. doi: 10.1016/j.jcjd.2013.02.054 24070844

38. Khan H, Lasker SS, Chowdhury TA. Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled Type 2 diabetes in East London. Diabet Med. 2008;25: 1108–1111. doi: 10.1111/j.1464-5491.2008.02538.x 19183316

39. Patel N, Stone MA, Chauhan A, Davies MJ, Khunti K. Insulin initiation and management in people with Type2 diabetes in an ethnically diverse population: The healthcare provider perspective. Diabet Med. 2012. doi: 10.1111/j.1464-5491.2012.03669.x 22486745

40. Sinclair AJ, Bayer AJ, Girling AJ, Woodhouse KW. Older adults, diabetes mellitus and visual acuity: a community-based case-control study. Age Ageing. 2000;29: 335–339. doi: 10.1093/ageing/29.4.335 10985443

41. Dixon DL, Sharma G, Sandesara PB, Yang E, Braun LT, Mensah GA, et al. Therapeutic Inertia in Cardiovascular Disease Prevention: Time to Move the Bar. J Am Coll Cardiol. 2019. doi: 10.1016/j.jacc.2019.08.014 31558257

42. Khunti K, Kosiborod M, Ray KK. Legacy benefits of blood glucose, blood pressure and lipid control in individuals with diabetes and cardiovascular disease: Time to overcome multifactorial therapeutic inertia? Diabetes, Obesity and Metabolism. Blackwell Publishing Ltd; 2018. pp. 1337–1341. doi: 10.1111/dom.13243

43. Potthoff S, Presseau J, Sniehotta FF, Breckons M, Rylance A, Avery L. Exploring the role of competing demands and routines during the implementation of a self-management tool for type 2 diabetes: A theory-based qualitative interview study. BMC Med Inform Decis Mak. 2019. doi: 10.1186/s12911-019-0744-9 30678684

44. Boels AM, Koning E, Vos RC, Khunti K, Rutten GEHM. Individualised targets for insulin initiation in type 2 diabetes mellitus—the influence of physician and practice: a cross-sectional study in eight European countries. BMJ Open. 2019; 1–11. doi: 10.1136/bmjopen-2019-030833

45. Mauricio D, Meneghini L, Seufert J, Liao L, Wang H, Tong L, et al. Glycaemic control and hypoglycaemia burden in patients with type 2 diabetes initiating basal insulin in Europe and the USA. Diabetes, Obes Metab. 2017. doi: 10.1111/dom.12927 28251792


Článek vyšel v časopise

PLOS Medicine


2020 Číslo 5

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Kurzy

Zvyšte si kvalifikaci online z pohodlí domova

Nová éra v léčbě migrény
nový kurz
Autoři: MUDr. Eva Medová, MUDr. Tomáš Nežádal, Ph.D.

Význam nutraceutik u kardiovaskulárních onemocnění
Autoři:

Pneumowebinář
Autoři:

White paper - jak vidíme optimální péči o zubní náhrady
Autoři: MUDr. Jindřich Charvát, CSc.

Faktory ovlivňující léčbu levotyroxinem

Všechny kurzy
Přihlášení
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se