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Abstract

To investigate socio-economic inequalities in diabetes complications, and to examine factors that may explain these differences. Cross-sectional questionnaire survey of 770 individuals with diabetes among 40 general practices in Avon and Somerset. General practice, optometrist and eye hospital records over time (median 7 years) were analysed. Slope indices of inequality, odds ratios and incidence rate ratios were calculated to estimate the magnitude of inequality between the most and least educated, and the highest and lowest earning patients, adjusted for age, sex and type of diabetes, and clustering of outcomes within practices. The least educated patients were more likely than the most educated patients to have diabetic retinopathy [adjusted odds ratio (OR) 4.3; 95% confidence interval 0.8, 23.7] and heart disease (adjusted OR 3.6; 1.1, 11.8), had higher HbA1c levels (adjusted slope index of inequality 0.9; 0.3, 1.5), felt that diabetes more adversely affected their social and personal lives (adjusted slope index of inequality 0.8; 0.5, 1.1 Diabetes Care Profile units), were more likely to be recorded as non-compliant by their health professionals, and had lower rates of hospital attendance (adjusted rate ratio 0.43; 0.26, 0.71). However, they did not see themselves as less compliant, and had higher general practice attendance rates (adjusted rate ratio 1.5; 1.1, 2.2). Less educated and lower earning individuals with diabetes bear a larger burden of morbidity but use hospital care less. Health service resource allocation should reflect the distribution of chronic illness.

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Socioeconomic gradient in morbidity and mortality in people with diabetes: cohort study findings from the Whitehall Study and the WHO Multinational Study of Vascular Disease in Diabetes.

Mackenzie M. Shipley, Wayne J Fuller, N. Chaturvedi … (1998)

To assess whether the inverse socioeconomic mortality gradient observed in the general population persists in diabetic people. The Whitehall cohort study and the London cohort of the WHO multinational study of vascular disease in diabetes. London. 17,264 male civil servants (17,046 without diabetes, 218 with diabetes) aged 40-64 examined in 1967-9, and 300 people with diabetes aged 35-55 from London clinics examined in 1975-7. Both cohorts were followed up until January 1995. Mortality from all causes, cardiovascular disease, and ischaemic heart disease. In both cohorts people in the lower social groups were older, had higher blood pressure, and were more likely to smoke. In the Whitehall study, the prevalence of heart disease was higher in the lowest social group compared with the highest group, by 6% among non-diabetic people (P = 0.0001) and by 14% among diabetic subjects (P = 0.02). In the WHO study proteinuria was more common in the lowest social group compared with the highest (27% v 15%, P = 0.01), as was retinopathy (54% v 48%, P = 0.5). There was a clear socioeconomic gradient in all cause mortality in both cohorts, with death rates being about twice as high in the lowest compared with the highest social groups. In the Whitehall study this gradient was similar in both diabetic and non-diabetic subjects, and it persisted for mortality from cardiovascular disease and from ischaemic heart disease. About half of the increased risk of death in the lowest social group was accounted for by blood pressure and smoking. We confirm the existence of an inverse socioeconomic mortality gradient in diabetic people and suggest that this is largely due to conventional cardiovascular risk factors.

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Deprivation and cause specific morbidity: evidence from the Somerset and Avon survey of health.

M Grainge, Angela S. Frankel, J. Williams … (1996)

To investigate the association between cause specific morbidity and deprivation in order to inform the debates on inequalities in health and health services resource allocation. Cross sectional postal questionnaire survey ascertaining self reported health status, with validation of a 20% sample through general practitioner and hospital records. Inner city, urban, and rural areas of Avon and Somerset. Stratified random sample of 28,080 people aged 35 and over from 40 general practices. Age and sex standardised prevalence of various diseases; Townsend deprivation scores were assigned by linking postcodes to enumeration districts. Relative indices of inequality were calculated to estimate the magnitude of the association between socioeconomic position and morbidity. The response rate was 85.3%. The prevalence of most of the conditions rose with increasing material deprivation. The relative index of inequalilty, for both sexes combined, was greater than 1 for all conditions except diabetes. The conditions most strongly associated with deprivation were diabetic eye disease (relative index of inequality 3.21; 95% confidence interval 1.84 to 5.59), emphysema (2.72; 1.67 to 4.43) and bronchitis (2.27; 1.92 to 2.68). The relative index of inequality was significantly higher in women for asthma (P < 0.05) and in men for depression (P < 0.01). The mean reporting of prevalent conditions was 1.07 for the most deprived fifth of respondents and 0.77 in the most affluent fifth (P < 0.001). Material deprivation is strongly linked with many common diseases. NHS resource allocation should be modified to reflect such morbidity differentials.