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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3041 — Racial and Ethnic Differences in All-Cause Mortality in a National Cohort of Veterans with Type 2 Diabetes

Hunt KJ (REAP - Charleston), Gebregziabher M (REAP - Charleston), Lynch CP (REAP - Charleston), Axon RN (REAP - Charleston), Gilbert GE (REAP - Charleston), Carrae E (REAP - Charleston), Mauldin PD (REAP - Charleston), Egede LE (REAP - Charleston)

Objectives:
Previous studies have examined racial and ethnic mortality differences among individuals with diabetes; however, few studies have examined differences in a managed care setting such as the VHA while controlling for medication adherence. Therefore, we examined the relationship between race/ethnicity and all-cause mortality in a national cohort of veterans with type 2 diabetes controlling for relevant covariates.

Methods:
The study population consisted of 690,968 veterans with diabetes receiving prescriptions for insulin or oral hypoglycemic agents in 2002 who were followed until death, loss to follow-up, or through December 2006. Covariates included demographics (i.e., age, sex, marital status, service connectedness, rural/urban residence, geographic region), ICD-9 coded comorbidities, HbA1c, medication type and medication adherence defined by having a medication possession ratio of > = 80%. Hazard ratios (HRs) were calculated comparing non-Hispanic blacks (NHB), Hispanics and other/unknown/missing (OTH) to non-Hispanic Whites (NHW).

Results:
The study population was 72.86% NHW, 12.85% NHB, 5.11% Hispanic and 9.18% OTH, with a mean age 65.77 ± 11.17 years in 2002. During the follow-up period 34.24% died. After adjusting for demographic factors mortality HRs relative to NHWs were 1.01 (95% CI: 0.99, 1.02), 0.85 (95% CI: 0.83, 0.87) and 0.62 (95% CI: 0.60, 0.64) for NHB, Hispanic and OTH, respectively. Further adjusting for comorbidities, reduced HRs slightly in NHB [HR = 0.94 (95% CI: 0.92, 0.95 )] and attenuated HRs slightly in OTH [HR = 0.74 (95% CI:0.72, 0.76)], but did not alter HRs in Hispanics [HR = 0.84 (95% CI: 0.82, 0.87)]. Further, adjusting for HbA1c, mediation type and medication adherence reduced HRs in NHB [HR = 0.79 (95% CI:0.77, 0.80)], Hispanics [HR = 0.79 (95% CI:0.77, 0.81 )] and OTH [HR = 0.64 (95% CI: 0.62, 0.66)] .

Implications:
After controlling for demographics, Hispanics have a mortality advantage over NHW, while NHB do not. After further controlling for comorbidities, glycemic control and medication adherence, both Hispanics and NHB have a lower mortality risk than NHW.

Impacts:
In the VHA where racial/ethnic disparities in access to care are absent, controlling for differences in glycemic control, medication type and medication adherence increases the mortality advantage of NHB and Hispanic veterans with type 2 diabetes. Further studies of patient, provider and system-level factors are required.


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