Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994–2018: A Multiple Linked Cohort Study

Abstract

Purpose

The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ).

Patients and Methods

A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models.

Results

Among 36,267 patients, adjusted population AFs indicated 6.6(−30.8–33.3)% of PM, 17.1(5.8–27.0)% of MI, 35.3(22.6–46.0)% of stroke, 14.3(3.2–24.2)% of HF, and 15.9(6.7–24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3–25.4)% of PM, −3.3(−8.3–1.5)% of MI, −0.5(−6.7–5.3)% of stroke, 4.7(0.3–8.8)% of HF, 13.3(9.9–16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Māori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Māori and Pasifika.

Conclusion

Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Māori.

Keywords:

• stroke
• myocardial infarction
• heart failure
• end-stage renal disease
• premature mortality
• Māori

Acknowledgments

We thank the participating GPs, audit nurses and the DCSS executive group for their support.

Disclosure

The authors declare that they have no competing interests in this work.

Additional information

Funding

The DCSS was funded by the New Zealand Ministry of Health through Counties Manukau District Health Board. The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.