Abstract
Context:
A higher prevalence of diabetes-related complications is reported in minority populations; however, it is not known if there are racial disparities in diabetes care and outcomes in hospitalized patients.
Objective:
Our objective was to determine the association between hyperglycemia, in patients with and without diabetes mellitus (non-DM), and complications among different racial groups.
Design:
This observational study compared the frequency of hyperglycemia (blood glucose ≥180 mg/dL; 10 mmol/L) and DM and hospital complications between Black and White patients hospitalized patients between January 2012 and December 2013.
Setting and participants:
Adults admitted to medical and surgery services in two academic hospitals were included in this study.
Results:
Among 35 866 patients, there were 14 387 Black (40.1%) and 21 479 White patients (59.9%). Blacks had a higher prevalence of hyperglycemia (42.3% vs 36.7%, P < .0001) and DM (34.5% vs 22.8%, P < .0001) and a higher admission rate and mean daily blood glucose (P < .001). Blacks also had higher rates of complications (22.2% vs 19.2%, P < .0001), both in patients with DM (24.7 vs 22.9%, P = .0413) and non-DM with hyperglycemia (41.2% vs 37.2%, P = .0019). Using sequential modelling adjusted for age, gender, body mass index, comorbidities, and insurance coverage, non-DM Blacks with normoglycemia (odds ratio, 1.22; 95% confidence interval, 1.10–1.35) and non-DM Blacks with hyperglycemia (odds ratio, 1.18; 95% confidence interval, 1.04–1.33) had higher number of complications compared to Whites.
Conclusions:
Black patients have higher rates of hyperglycemia and diabetes, worse inpatient glycemic control, and greater frequency of hospital complications compared to Whites. Non-DM Blacks with hyperglycemia are a particularly vulnerable group. Further investigation is needed to better understand factors contributing the racial disparities in the hospital.
Racial disparities in the prevalence of diabetes mellitus (DM)-related complications have been reported in epidemiological studies (1). Blacks have a 1.9-fold higher incidence of type 2 diabetes (2) and have worse glycemic control (3, 4) compared to Whites. Blacks are two to four times more likely than Whites to experience diabetes-related complications such as amputation of the lower extremities, chronic kidney disease (CKD), renal disease, and retinopathy (1, 5–7). There is also evidence that Blacks receive lower quality health care as indicated by poorer glycemic control (8, 9) and fewer diabetes monitoring tests than non-Hispanic Whites. In addition, after adjusting for confounders, diabetic patients from ethnic minorities have been reported to have higher mortality rates compared to Whites (10). In a report of the 50 larger cities in the United States, Blacks had 1.6–3.8 times increased rates of diabetes-related mortality compared to Whites (11, 12). The cause for health disparities is not known, but several factors may play a role, including a genetic predisposition for more severe disease, differences in income and health insurance, and lower access to diabetes care (13–15). Differences in access and quality of care may also affect how comorbid conditions, such as hypertension and obesity, contribute to diabetes-related morbidity and mortality (13).
Despite the abundance of information on the higher prevalence of long-term complications of diabetes in minority populations, few studies have reported on racial disparities in the hospital setting. It is not known if racial disparities in diabetes management, hospital complications, or mortality are present among hospitalized patients with hyperglycemia and diabetes. Therefore, we aimed to investigate racial differences on the frequency of hyperglycemia in patients with and without diabetes, differences in glycemic control, insulin utilization, and hospital complications in the inpatient setting.
Research Design and Methods
We conducted a retrospective analysis of patients admitted to medical and surgical services at two Emory University Hospitals in Atlanta, Georgia, between January 2012 and December 2013. Approval for the study was obtained from the Institutional Review Board of Emory University. We obtained composite data for hospital complications as determined by International Classification of Diseases, ninth revision (ICD-9), codes generated during the hospitalization. Race was determined by patient-reported indicators collected during registration.
Patient population
There were a total of 42 484 patients during the study period, of which 16 465 (38.8%) were Black, 22 467(52.9%) were White, 349 (0.8%) were Hispanic, and 678 (1.6%) were other racial groups. Because of their small number, Hispanics and other racial groups were excluded from this analysis. Only patients age 18 or older admitted to adult surgery and medicine services were included. We excluded patients undergoing outpatient procedures, those with admission glucose greater than 400 mg/dL (22.2 mmol/liter), diabetic ketoacidosis, hyperosmolar hyperglycemic state, and end-stage renal disease on dialysis or with estimated glomerular filtration rate lower than 15 mL/min. The final study population included 35 866 patients.
Data acquisition
The Clinical Data Warehouse infrastructure program from the Emory University electronic health record and billing systems was used for data extraction. The Clinical Data Warehouse is a comprehensive searchable database that stores information of patient encounters since September 1998. Major data sources include Emory's electronic medical record, hospital and outpatient clinic billing, and Emory Medical Laboratory's pathology information. Data were extracted from Emory University Hospital and Emory University Hospital Midtown between January 2012 and December 2013.
The following set of data was extracted for each patient during his or her first hospitalization during the study time period: age; gender; body mass index (BMI); admission service (medicine vs surgery); ICU treatment; comorbidities; hospital complications; insulin utilization; insurance coverage including governmental (Medicare and Medicaid), private or uninsured; and glucose values on admission and during the hospital stay.
The diagnoses of diabetes, comorbidities, and complications were identified by ICD-9 codes. Complications included a composite of pneumonia, bacteremia, myocardial infarction, respiratory failure, acute kidney injury, and death. Acute kidney injury was defined by a rise in serum creatinine by 50% above admission value at any point during the hospitalization. Comorbidities were determined using ICD-9 codes present at the time of hospitalization for the following chronic conditions: coronary artery disease (CAD), hypertension, CKD, chronic obstructive pulmonary disease (COPD), and dyslipidemia. To avoid misclassification of complications and presenting diagnoses, we included new complications generated during the hospital stay, which were not present on admission. Glucose values were collected from bedside point of care testing and laboratory serum values on admission and during the hospital stay. In patients without DM (non-DM), hyperglycemia was defined by a maximum blood glucose level of at least 180 mg/dL (10.0 mmol/liter) during hospitalization.
Statistical analysis
The primary objective was to determine the frequency of hyperglycemia and diabetes and the association between hyperglycemia and a composite of complications among Black and White patients. Descriptive statistics were used to examine the distribution of patient demographics and presence of comorbidities including CKD, CAD, hypertension, and COPD. Continuous variables were compared using parametric (independent two-sample t test) and nonparametric (Wilcoxon rank sum test) and expressed as mean ± SD. Categorical variables were expressed by frequency and proportion. A two-tailed P value of less than .05 was considered statistically significant.
Multiple logistic regression with sequential modeling was used to estimate the association between race and complications. The first model (model 1) was adjusted for patient demographics including age, gender, and BMI (overweight [25–29.9 kg/m2]; obese [≥30 kg/m2] vs lean [<25 kg/m2]). The second model (model 2) was additionally adjusted for patient comorbidities including CAD, CKD, hypertension, hyperlipidemia, and COPD. The association was analyzed in all patients, and patients with and without diabetes. Standard diagnostic and model checking procedures, such as deviance residual plot and Hosmer-Lemeshow test, were applied to examine the fit of the developed models. Crude and adjusted odds ratios are reported. Statistical analyses were performed with the Statistical Analysis System, version 9.4.
Results
Of the 35 866 patients in the analysis, 14 387 (40.1%) were Black and 21 479 (59.9%) were White. Of these, 51.1% were admitted to medicine and 48.9% to surgical services. Blacks had a higher frequency of diabetes (34.5% vs 22.8%, P < .0001) and hyperglycemia (42.3% vs 36.7%, P < .0001) (Table 1). In addition, Black patients were younger, had higher BMI, and a higher proportion of obesity. Black patients were also more likely to be admitted to medicine services than surgery services and to have higher rates of comorbidities including hypertension and CKD (all P < .0001).
Table 1.
Demographic and Clinical Characteristics Among Blacks and Whites
| Blacks (n = 14 387) | Whites (n = 21 479) | P Value | |
|---|---|---|---|
| Age at admission, y | 57.5 ± 16.8 | 61.9 ± 16.2 | <.0001 |
| Male gender, n (%) | 6118 (42.5) | 11 422 (53.2) | <.0001 |
| Weight, kg | 88.1 ± 124.4 | 85.2 ± 126.3 | .05 |
| BMI, kg/m2 | 29.5 ± 8.2 | 28.1 ± 6.6 | <.0001 |
| Normal, BMI <25, n (%) | 3648 (32.2) | 6340 (34.6) | |
| Overweight, BMI 25–29, n (%) | 2992 (26.4) | 5968 (32.6) | |
| Obese, BMI >30, n (%) | 4685 (41.4) | 5990 (32.7) | |
| Admission service | |||
| Medicine, n (%) | 9244 (64.3) | 9067 (42.2) | <.0001 |
| Surgery, n (%) | 5143 (35.7) | 12 412 (57.8) | |
| Unit | .43 | ||
| ICU, n (%) | 227 (1.6) | 362 (1.7) | |
| Non ICU, n (%) | 14 160 (98.4) | 21 117 (98.3) | |
| History of diabetes, n (%) | 4962 (34.5) | 4896 (22.8) | <.0001 |
| Hemoglobin A1c, % | 6.7 ± 2.1 | 6.2 ± 1.4 | <.0001 |
| No. patients with BG ≥180 mg/dL | 6090 (42.3) | 7879 (36.7) | <.0001 |
| LOS, media | 4 (2–8) | 4 (2–7) | <.0001 |
| Comorbidities | |||
| CAD, n (%) | 2144 (14.9) | 4565 (21.3) | <.0001 |
| Hypertension, n (%) | 7084 (49.2) | 10 115 (47.1) | <.0001 |
| CKD, n (%) | 2738 (19.0) | 2446 (11.4) | <.0001 |
| Hyperlipidemia, n (%) | 4029 (28.0) | 7417 (34.5) | <.0001 |
| COPD, n (%) | 1344 (9.3) | 2514 (11.7) | <.0001 |
Abbreviations: BG, blood glucose; LOS, length of stay.
Glycemic control and insulin treatment
Black patients had higher average blood glucose level on admission and during the hospital stay compared to Whites (both P < .0001), Table 2. A total of 38% of patients had hemoglobin A1c (HbA1c) measured during hospitalization or within 30 days before or after discharge; in these subjects, Blacks had higher HbA1c values (P < .0001) compared to Whites. Among DM patients, the average HbA1c on admission was 7.7 ± 2.4% for Blacks compared to 7.1 ± 2.4% for Whites, P < .001.
Table 2.
Glycemic Control, Insulin Treatment, and Complications
| Blacks | Whites | P Value | |
|---|---|---|---|
| BG levels for all patients | |||
| Admission glucose, mg/dL | 139.0 ± 56 | 135.7 ± 45 | <.0001 |
| Mean glucose during first 48 h, mg/dL | 134.2 ± 47 | 131.2 ± 38 | <.0001 |
| Mean daily glucose during hospitalization, mg/dL | 130.8 ± 40 | 128.4 ± 33 | <.0001 |
| BG for patients with diabetes | |||
| Admission glucose, mg/dL | 170.7 ± 68 | 166.3 ± 59 | .0009 |
| Mean glucose during first 48 h, mg/dL | 165.5 ± 57 | 162.3 ± 49 | .0032 |
| Mean daily glucose during hospitalization, mg/dL | 159.1 ± 47 | 157.4 ± 41 | .06 |
| BG for patients without diabetes | |||
| Admission glucose, mg/dL | 119.3 ± 34 | 124.9 ± 33 | <.0001 |
| Mean glucose during first 48 h, mg/dL | 117.5 ± 29 | 121.9 ± 28 | <.0001 |
| Mean daily glucose during hospitalization, mg/dL | 116.0 ± 25 | 119.9 ± 24 | <.0001 |
| Insulin treatment | |||
| All patients, n (%) | 5478 (38.1) | 7098 (33.0) | <.0001 |
| Patients with diabetes, n (%) | 3752 (75.6) | 3552 (72.6) | .0005 |
| Non-DM with BG ≥180 mg/dL, n (%) | 1396 (62.7) | 2741 (66.1) | .0065 |
| Number of blood glucose checks, median | 10 (4 − 27) | 7 (3–25) | <.0001 |
| Hospital complications | |||
| Non-DM with normoglycemia | |||
| Composite complications, n (%) | 1058 (15) | 1468 (12) | <.001 |
| In-hospital mortality, n (%) | 43 (1) | 78 (1) | .80 |
| Myocardial infarction, n (%) | 117 (2) | 157 (1) | .037 |
| Pneumonia, n (%) | 481 (7) | 585 (5) | <.001 |
| Respiratory failure, n (%) | 287 (4) | 547 (4) | .17 |
| Acute kidney injury, n (%) | 1155 (16) | 1108 (9) | <.001 |
| Non-DM with hyperglycemia | |||
| Composite complications, n (%) | 916 (41.2) | 1541 (37.2) | .0019 |
| In-hospital mortality, n (%) | 138 (6.2) | 195 (4.7) | .0106 |
| Myocardial infarction, n (%) | 169 (7.6) | 225 (5.4) | .0006 |
| Pneumonia, n (%) | 306 (13.7) | 463 (11.2) | .0026 |
| Respiratory failure, n (%) | 607 (27.3) | 1097 (26.5) | .49 |
| Acute kidney injury, n (%) | 370 (16.6) | 603 (14.5) | .0282 |
| Diabetes | |||
| Composite complications, n (%) | 1225 (24.7) | 123 (22.9) | .0413 |
| In-hospital mortality, n (%) | 89 (1.8) | 89 (1.8) | .93 |
| Myocardial infarction, n (%) | 198 (4.0) | 162 (3.3) | .07 |
| Pneumonia, n (%) | 473 (9.5) | 412 (8.4) | .05 |
| Respiratory failure, n (%) | 487 (9.8) | 555 (11.3) | .0140 |
| Acute kidney injury, n (%) | 538 (10.8) | 453 (9.3) | .19 |
Abbreviations: BG, Blood glucose; DM, diabetes mellitus; non-DM, patients without diabetes mellitus.
More Black patients received insulin therapy during their hospital stay compared to Whites. In the entire cohort, 38.1% of Black and 33.0% of White patients received insulin therapy, P < .0001. Among patients with a known diagnosis of diabetes before admission, a higher number of Blacks received insulin (75.6% vs 72.6%; P = .0005) compared to Whites. Non-DM Black patients with hyperglycemia, however, were less likely to receive insulin compared to Whites (62.7% vs 66.1%, P = .0065), Table 2.
Hyperglycemia, hospital complications, and mortality
Black patients had higher rates of the composite of complications that included pneumonia, bacteremia, myocardial infarction, respiratory failure, acute kidney injury, and death compared to Whites, Table 2. This was seen in the entire patient population as well as the subgroups of patients with and without DM (all patients, 22.2% vs 19.2%, P < .0001; DM, 24.7% vs 22.9%, P = .0413; non-DM with hyperglycemia, 41.2% vs 37.2%, P = .0019). In addition, Black and White patients with hyperglycemia and diabetes had significantly higher rates of complications compared to White patients with normoglycemia, Table 3. Compared to non-DM White subjects with normoglycemia, the odds ratio (OR) for complications among non-DM Blacks with hyperglycemia was 5.00 (95% confidence interval [CI], 4.43–5.65) and 4.22 (95% CI, 3.85–4.63) for non-DM Whites with hyperglycemia in the fully adjusted models (Table 3). Similarly, the rate of hospital complications was 2- to 3-fold higher in patients with DM compared to non-DM White patients with normoglycemia.
Table 3.
Association Between Hyperglycemia and Complications With Reference of Non-DM Whites With Normoglycemia
| Composite Complications | ||||
|---|---|---|---|---|
| Unadjusted ORa | Model 1b | Model 2c | Model 3d | |
| BG categories | ||||
| White non-DM with normoglycemia | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) |
| Black non-DM with normoglycemia | 1.29 (1.18–1.40) | 1.37 (1.24–1.51) | 1.34 (1.21–1.48) | 1.22 (1.10–1.35) |
| White non-DM with hyperglycemia | 4.42 (4.07–4.81) | 4.43 (4.04–4.86) | 4.27 (3.89–4.69) | 4.22 (3.85–4.63) |
| Black non-DM with hyperglycemia | 5.23 (4.73–5.78) | 5.65 (5.05–6.34) | 5.42 (4.82–6.09) | 5.00 (4.43–5.65) |
| White DM | 2.22 (2.04–2.42) | 2.28 (2.07–2.52) | 2.16 (1.95–2.39) | 2.13 (1.92–2.36) |
| Black DM | 2.45 (2.25–2.67) | 2.64 (2.39–2.91) | 2.38 (2.14–2.64) | 2.24 (2.01–2.51) |
Crude odds ratio.
Model 1 adjusted for age, gender, body mass index.
Model 2: model 1 + comorbidities: coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease, and chronic obstructive pulmonary disease.
Model 3: model 2 + insurance type.
Abbreviations: BG, blood glucose; DM, diabetes mellitus.
Figure 1 depicts the association of glycemic status and race with the presence of hospital complications in the unadjusted analysis and after sequential modeling. Model 1 was adjusted for age, gender, and BMI; model 2 was additionally adjusted for comorbidities; and model 3 was adjusted for insurance coverage as well as all variables included in model 2. Among non-DM patients with normoglycemia, Blacks had a higher number of complications in both the unadjusted and adjusted models (unadjusted OR, 1.29 [1.18–1.40]; model 1 OR, 1.37 [1.24–1.51]; model 2 OR, 1.34 [1.21–1.48]; model 3 OR, 1.22 [1.10–1.35]). In addition, we found that among non-DM patients with hyperglycemia, Blacks had a significantly higher rate of complications (unadjusted OR, 1.18; 95% CI, 1.06–1.31; model 1 OR, 1.25; 95% CI, 1.11–1.41; model 2 OR, 1.26, 95% CI, 1.11–1.42; model 3 OR, 1.18, 95% CI, 1.04–1.33) compared to non-DM White patients with hyperglycemia; however, the difference in composite complications between Black and White patients with DM did not reach statistical significance in the fully adjusted model (unadjusted OR, 1.1; 95% CI, 1.0–1.21; model 1 OR, 1.14, 95% CI, 1.02–1.26; model 2 OR, 1.13, 95% CI, 1.01–1.26; model 3,: 1.01, 95% CI, 0.98–1.22).
Figure 1.
Composite complications based on glycemic status for Black vs Whites. Odds ratios for composite complications in Black (n = 14 387) and White (n = 21 479) patients using sequential modeling. Unadjusted: Unadjusted OR. Model 1: adjusted for age, gender, and BMI. Model 2: model 1 + comorbidities including CAD, hypertension, hyperlipidemia, chronic kidney disease, and COPD. Model 3: model 2 + insurance type.
There were no differences in the overall mortality rate between Black and White patients or between the two racial groups with normoglycemia or with a history of diabetes (Table 2). However, mortality was higher among non-DM Blacks with hyperglycemia compared to their White counterpart. Compared to Whites, the OR for mortality, adjusted for age, gender, and BMI, was 1.55 (1.19–2.02) in non-DM Blacks with hyperglycemia.
Discussion
This study compared differences in the frequency of inpatient hyperglycemia and diabetes and their impact on clinical outcomes in White and Black patients. Our study indicates that Blacks had a higher prevalence of hyperglycemia and diabetes compared to White patients. In addition, we found that Blacks had a higher number of hospital complications. In multivariate adjusted models, the higher number of complications in Blacks was significant in non-DM patients with normoglycemia and hyperglycemia, but did not reach statistical significance in patients with a history of DM when adjusted for demographics, comorbidities, and insurance type.
Cefalu and Golden recently reported on the importance of personalized treatment strategies and need for improved understanding of racial differences that can impact diabetes care and outcomes (16). Several studies have reported on the presence of racial disparities with higher prevalence of diabetes as well as chronic complications, lower quality care, and poorer outcomes for diabetes in Blacks compared to White patients (3, 10). In the United States, Blacks have 1.9-fold higher incidence of type 2 diabetes compared to Whites (2), a disparity observed throughout the lifespan (17). Blacks have been shown to have worse diabetes control and higher rates of microvascular complications, which persisted even when treatments were similar among the populations (3, 4). Blacks have two to four times the rate of renal disease, blindness, amputations, and amputation-related mortality (4, 9). In addition, after adjusting for confounders, Blacks with diabetes have higher mortality rates compared to Whites (10). Our study indicates that racial disparities are also present in the inpatient setting. We found that Black patients had higher admission HbA1c and glucose values and had worse glycemic control during the hospital stay despite a higher use of insulin during the hospital stay. The higher BMI, greater number of obese patients, and worse glycemic control (HbA1c) before admission may explain the worse glycemic control in Black patients. We recently reported that the admission HbA1c is the best predictor for inpatient glycemic control in insulin-treated patients (18).
Our study confirms previous reports that the development of hyperglycemia in patients without a history of diabetes is associated with higher rates of hospital complications and longer length of hospital stay compared to patients with diabetes (19–23). In addition, our results indicate that nondiabetic patients with hyperglycemia, independent of race, had increased risk of complications compared to patients with a history of diabetes. The rate of hospital complications in non-DM patients with hyperglycemia was greater than 4- to 6-fold compared to patients with normoglycemia and were 1- to 3-fold higher in patients with diabetes. Several factors may account for the racial difference in hospital complications, including worse glycemic control before and during hospitalization and a higher number of comorbidities such as hypertension and CKD in Blacks compared to Whites.
We acknowledge several limitations in our analysis. The study is retrospective and based on data from ICD-9 codes, with fewer than half of patients with measured HbA1c to assess long-term glycemic control before admission. Although the present study included a number of comorbidities including CAD, hypertension, CKD, COPD, and dyslipidemia in the multivariate-adjusted analysis, the database was limited in its lack of a comprehensive comorbidity score or case mix index. In addition, we did not evaluate for differences in education status, income, and geographic factors, which could affect access to resources before hospitalization. Our study did not address the question of whether treatment of hyperglycemia in patients with and without diabetes may reduce hospital complications. These variables may be considered in future randomized controlled trials to help better understand why racial differences can affect hospital complications.
In summary, we report the presence of racial disparities in inpatient care, with Black patients having a higher frequency of diabetes and hyperglycemia, worse glycemic control, and higher hospital complications compared to White patients. We also identified nondiabetic Blacks with hyperglycemia as a particularly vulnerable group. Understanding the predisposing vulnerability of racial and ethnic minorities can help us to direct concerted efforts to help narrow disparities in health care.
Acknowledgments
Disclosure Summary: The present study was supported by an unrestricted grant from the Jacobs Family Research Fund (to Emory University and G.E.U.). G.E.U. is supported in part by research grants from the American Diabetes Association (1–14-LLY-36), Public Health Service grant UL1 RR025008 from the Clinical Translational Science Award Program (M01 RR-00 039), National Institutes of Health, National Center for Research Resources, and has received unrestricted research support for inpatient studies (to Emory University) from Merck, Novo Nordisk, Boehringer Ingelheim, and Sanofi; and has received consulting fees or/and honoraria for membership in advisory boards from Novo Nordisk, Sanofi, Merck, Regeneron, and Boehringer Ingelheim. D.S. has received research support (to Emory University) from Abbott, Merck, and Sanofi and received for participation in advisory committees from Jansen, Sanofi, and Boehringer Ingelheim. M.F., A.-S.A., L.B., L.Z., F.J.P., J.W., and P.V. have no conflicts to report.
The abstract of this study was previously presented at the American Association of Clinical Endocrinologists national meeting in May 2014.
Footnotes
- BMI
- body mass index
- CAD
- coronary artery disease
- CI
- confidence interval
- CKD
- chronic kidney disease
- COPD
- chronic obstructive pulmonary disease
- DM
- diabetes mellitus
- HbA1c
- hemoglobin A1c
- ICD-9
- International Classification of Diseases, ninth revision
- OR
- odds ratio.
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