Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.
Department of Medicine, Division of Endocrinology, Diabetes Research Center, Columbia University Irving Medical Center, New York, New York.
JAMA Netw Open. 2023 Oct 2;6(10):e2336307. doi: 10.1001/jamanetworkopen.2023.36307.
Poor access to care and lack of health insurance are important contributors to disparities in glycemic control. However expanding health insurance coverage may not be enough to fully address the high burden of poor glycemic control for some groups.
To characterize racial and ethnic disparities in glycemic control among adults with private and public insurance in the US over a 15-year timeframe and to evaluate whether social, health care, and behavioral or health status factors attenuate estimates of disparities.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the National Health and Nutrition Examination Survey from 2003 to 2018. Participants included Hispanic or Latino, non-Hispanic Black, and non-Hispanic White adults aged 25 to 80 years with self-reported diabetes and health insurance. Data were analyzed from January 15 to August 23, 2023.
Participants self-identified as Hispanic or Latino, non-Hispanic Black, or non-Hispanic White.
The main outcome, poor glycemic control, was defined as glycated hemoglobin A1c (HbA1c) of 7.0% or greater. Information about social (education, food security, and nativity), health care (insurance type, routine place for health care, insurance gap in past year, and use of diabetes medications), and behavioral or health status (years with diabetes, waist circumference, and smoking) factors were collected via questionnaires.
A total of 4070 individuals (weighted mean [SE] age, 61.4 [0.27] years; 1970 [weighted proportion, 49.3%] were women) were included, representing 16 337 362 US adults, including 1146 Hispanic or Latino individuals (weighted proportion, 13.2%), 1196 non-Hispanic Black individuals (weighted proportion, 15.7%), and 1728 non-Hispanic White individuals (weighted proportion, 71.1%). In models adjusted for age, sex, and survey year, Hispanic or Latino and non-Hispanic Black individuals had significantly higher odds of poor glycemic control than non-Hispanic White individuals (Hispanic or Latino: odds ratio [OR], 1.46; 95% CI, 1.16-1.83; Black: OR, 1.28; 95% CI, 1.04-1.57). There was some attenuation after adjustment for social factors, especially food security (Hispanic or Latino: OR, 1.39; 95% CI, 1.08-1.81); Black: OR, 1.39; 95% CI, 1.08-1.81). However, accounting for health care and behavioral or health status factors increased disparities, especially for Hispanic or Latino individuals (OR, 1.63; 95% CI, 1.24-2.16), with racial and ethnic disparities persisting even among those with private insurance (OR, 1.66; 95% CI, 1.10-2.52).
In this cross-sectional study of insured adults with diabetes in the US, disparities in poor glycemic control persisted despite adjustment for social, health care, and behavioral factors. Research is needed to identify the barriers contributing to poor control even in populations with access to care.
重要性：医疗保健获取不足和缺乏健康保险是导致血糖控制差异的重要因素。然而，扩大健康保险覆盖范围可能不足以完全解决某些群体血糖控制不佳的高负担。
目的：在 15 年的时间内，描述美国拥有私人和公共保险的成年人在血糖控制方面的种族和族裔差异，并评估社会、医疗保健以及行为或健康状况因素是否会降低差异估计值。
设计、地点和参与者：这项横断面研究使用了 2003 年至 2018 年全国健康和营养调查的数据。参与者包括 25 岁至 80 岁有自我报告糖尿病和健康保险的西班牙裔或拉丁裔、非西班牙裔黑人和非西班牙裔白人成年人。数据分析于 2023 年 1 月 15 日至 8 月 23 日进行。
暴露：参与者自我认定为西班牙裔或拉丁裔、非西班牙裔黑人和非西班牙裔白人。
主要结果和措施：主要结果是血糖控制不佳，定义为糖化血红蛋白 A1c（HbA1c）大于或等于 7.0%。通过问卷收集了有关社会（教育、食品安全和出生地）、医疗保健（保险类型、常规医疗保健场所、去年保险缺口以及使用糖尿病药物）以及行为或健康状况（糖尿病患病年限、腰围和吸烟状况）的信息。
结果：共有 4070 人（加权平均[SE]年龄为 61.4[0.27]岁；1970 人[加权比例为 49.3%]为女性）被纳入研究，代表了 16337362 名美国成年人，其中包括 1146 名西班牙裔或拉丁裔个体（加权比例为 13.2%）、1196 名非西班牙裔黑人个体（加权比例为 15.7%）和 1728 名非西班牙裔白人个体（加权比例为 71.1%）。在调整年龄、性别和调查年份的模型中，西班牙裔或拉丁裔和非西班牙裔黑人个体的血糖控制不佳的可能性显著高于非西班牙裔白人个体（西班牙裔或拉丁裔：比值比[OR]，1.46；95%置信区间[CI]，1.16-1.83；黑人：OR，1.28；95%CI，1.04-1.57）。在调整社会因素后，这种差异有所减弱，尤其是在食品安全方面（西班牙裔或拉丁裔：OR，1.39；95%CI，1.08-1.81；黑人：OR，1.39；95%CI，1.08-1.81）。然而，考虑到医疗保健和行为或健康状况因素会增加差异，尤其是对于西班牙裔或拉丁裔个体（OR，1.63；95%CI，1.24-2.16），即使在拥有私人保险的人群中，种族和族裔差异仍然存在（OR，1.66；95%CI，1.10-2.52）。
结论和相关性：在这项对美国有保险的糖尿病成年患者的横断面研究中，尽管调整了社会、医疗保健和行为因素，但血糖控制不佳的差异仍然存在。需要研究以确定导致控制不佳的障碍，即使在有医疗保健机会的人群中也是如此。
