Kahkoska_Online_Only_Supplemental_Material.pdf (326.33 kB)
Download file

The Impact of Racial and Ethnic Health Disparities in Diabetes Management on Clinical Outcomes: A Reinforcement Learning Analysis of Health Inequity Among Youth and Young Adults in the SEARCH for Diabetes in Youth Study

Download (326.33 kB)
figure
posted on 02.11.2021, 13:58 by Anna R. Kahkoska, Teeranan Pokaprakarn, G. Rumay Alexander, Tessa L. Crume, Dana Dabelea, Jasmin Divers, Lawrence M. Dolan, Elizabeth T. Jensen, Jean M. Lawrence, Santica Marcovina, Amy K. Mottl, Catherine Pihoker, Sharon H. Saydah, Michael R. Kosorok, Elizabeth J. Mayer-Davis
Objective: To estimate difference in population-level glycemic control and the emergence of diabetes complications given a theoretical scenario whereby non-White youth and young adults (YYA) with type 1 diabetes (T1D) receive and follow an equivalent distribution of diabetes treatment regimens as non-Hispanic White YYA.

Research Design and Methods: Longitudinal data from YYA diagnosed 2002-2005 in the SEARCH for Diabetes in Youth Study were analyzed. Based on self-reported race/ethnicity, YYA were classified as non-White race or Hispanic ethnicity (non-White subgroup) versus non-Hispanic White race (White subgroup). In the White versus non-White subgroups, propensity scores model estimated treatment regimens, including patterns of insulin modality, self-monitored glucose frequency, and continuous glucose monitoring use. An analysis based on policy evaluation technique in reinforcement learning estimated the effect of each treatment regimen on hemoglobin A1c (HbA1c) and diabetes complications for non-White YYA.

Results: The study included n=978 YYA. The sample was 47.5% female and77.5% non-Hispanic White, with mean age 12.8±2.4 years at diagnosis. The estimated population mean of longitudinal average HbA1c over visits was 9.2% and 8.2% for the non-White and White subgroup, respectively (difference=0.9%). Within the non-White subgroup, mean HbA1c across visits was estimated to decrease by 0.33% (95%CI: -0.45%, -0.21%) if these YYA received the distribution of diabetes treatment regimens of the White subgroup, explaining approximately 35% of the estimated difference between the two subgroups. The non-White subgroup was also estimated to have a lower risk of developing diabetic retinopathy, diabetic kidney disease, and peripheral neuropathy with the White youth treatment regimen distribution (p<0.05), although the low proportion of YYA who developed complications limited statistical power for risk estimations.

Conclusions: Mathematically modeling an equalized distribution of T1D self-management tools and technology accounted for part but not all disparities in glycemic control between non-White and White YYA, underscoring the complexity of race/ethnicity-based health inequity.

Funding

The SEARCH for Diabetes in Youth Study is indebted to the many youth and their families, and their health care providers, whose participation made this study possible. Grant Support (SEARCH 4): The SEARCH for Diabetes in Youth Cohort Study (1R01DK127208-01, 1UC4DK108173) is funded by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and supported by the Centers for Disease Control and Prevention. The Population Based Registry of Diabetes in Youth Study (1U18DP006131, U18DP006133, U18DP006134, U18DP006136, U18DP006138, and U18DP006139) is funded by the Centers for Disease Control and Prevention (DP-15-002) and supported by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Grant Support (SEARCH 1, 2, 3): SEARCH for Diabetes in Youth is funded by the Centers for Disease Control and Prevention (PA numbers 00097, DP-05-069, and DP-10-001) and supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Kaiser Permanente Southern California (U48/CCU919219, U01 DP000246, and U18DP002714), University of Colorado Denver (U48/CCU819241-3, U01 DP000247, and U18DP000247-06A1), Cincinnati's Children's Hospital Medical Center (U48/CCU519239, U01 DP000248, and 1U18DP002709), University of North Carolina at Chapel Hill (U48/CCU419249, U01 DP000254, and U18DP002708), Seattle Children's Hospital (U58/CCU019235-4, U01 DP000244, and U18DP002710-01] and Wake Forest University School of Medicine (U48/CCU919219, U01 DP000250, and 200-2010-35171). The authors wish to acknowledge the involvement of the Kaiser Permanente Southern California’s Clinical Research Center (funded by Kaiser Foundation Health Plan and supported in part by the Southern California Permanente Medical Group; the South Carolina Clinical & Translational Research Institute, at the Medical University of South Carolina, NIH/National Center for Advancing Translational Sciences (NCATS) grant number UL1

History