title: Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study.
abstract: BACKGROUND
  Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes.
  
  
  METHODS
  We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control.
  
  
  RESULTS
  The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c > or = 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control.
  
  
  CONCLUSIONS
  In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.
authors.affiliation: Southern Arizona VA Health Care System, Tucson, AZ 85723, USA. Christopher.Wendel@va.gov
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Wendel
authors.forename: Jayendra H
authors.initials: JH
authors.lastname: Shah
authors.forename: William C
authors.initials: WC
authors.lastname: Duckworth
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hoffman
authors.forename: M Jane
authors.initials: MJ
authors.lastname: Mohler
authors.forename: Glen H
authors.initials: GH
authors.lastname: Murata
mesh_terms: D001741:Black or African American / Q000523:psychology; D000368:Aged; D002318:Cardiovascular Diseases / Q000150:complications / Q000208:ethnology* / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006630:Hispanic or Latino / Q000523:psychology; D006787:Hospitals, Veterans; D006801:Humans; D007328:Insulin / Q000008:administration & dosage* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D012959:Socioeconomic Factors; D015206:Southwestern United States / Q000453:epidemiology; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000145:classification* / Q000523:psychology; D044465:White People / Q000523:psychology
chemical_list: D006442:Glycated Hemoglobin; D007328:Insulin