Disparities in glycaemic control, monitoring, and treatment of type 2 diabetes in England: A retrospective cohort analysis

Abstract

Background

Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D.

Methods and findings

A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate [eGFR]), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population ( n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m ². The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio [OR] 0.86, 95% CI 0.79–0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58–0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31–0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39–0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35–0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79–0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70–0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01–1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00–1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79–0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80–0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation.

Conclusions

Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.

Abstract

Martin Brunel Whyte and colleagues reveal disparities in diabetes monitoring and treatment for patients of different ethnicites in England.

Author summary

Why was this study done?

• There are few studies of ethnic disparities in diabetes care conducted in healthcare systems free at the point of delivery and with adjustment for socioeconomic status. These have generally shown overall improvement in diabetes management and outcomes over time, but with persistent imbalance between population groups.

• A number of initiatives have attempted to redress disparity of care in diabetes management in the UK over the last decade.

What did the researchers do and find?

• We set out to determine whether there are healthcare disparities (inequalities between the sexes or across socioeconomic and ethnic groups) in the care of people with type 2 diabetes.

• We analysed routinely collected data from a network of primary care practices in England for measures of clinical outcomes, prescribing, and care processes for individuals with type 2 diabetes.

• Our study provides up-to-date information on care processes and metabolic outcomes for type 2 diabetes mellitus.

• We found disparities in glycaemic control, disease monitoring, and prescribing between ethnicities and socioeconomic groups, and a weak difference between the sexes.

What do these findings mean?

• The commissioning of diabetes services must continue with the ambition to reduce inequalities and thereby improve population health for individuals with type 2 diabetes.