Jia Pu

Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors

BACKGROUND The White House, the American Heart Association, the Agency for Healthcare Research and Quality, and the National Heart, Lung and Blood Institute have all recently acknowledged the need to disaggregate Asian American subgroups to better understand this heterogeneous racial group. This study aims to assess racial/ethnic differences in relative contribution of risk factors of gestational diabetes mellitus (GDM) among Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese), Hispanics, non-Hispanic blacks, and non-Hispanic whites. METHODS Pregnant women in 2007-2012 were identified through California state birth certificate records and linked to the electronic health records in a large mixed-payer ambulatory care organisation in Northern California (n = 24 195). Relative risk and population attributable fraction (PAF) for specific racial/ethnic groups were calculated to assess the contributions of advanced maternal age, overweight/obesity (Centers for Disease Control and Prevention (CDC) standards and World Health Organization (WHO)/American Diabetes Association (ADA) body mass index cut-offs for Asians), family history of type 2 diabetes, and foreign-born status. RESULTS GDM was most prevalent among Asian Indians (19.3%). Relative risks were similar across all race/ethnic groups. Advanced maternal age had higher PAFs in non-Hispanic whites (22.5%) and Hispanics (22.7%). Meanwhile family history (Asian Indians 22.6%, Chinese 22.9%) and foreign-borne status (Chinese 40.2%, Filipinos 30.2%) had higher PAFs in Asian subgroups. Overweight/obesity was the most important GDM risk factor for non-Hispanic whites, Hispanics, Asian Indians, and Filipinos when the WHO/ADA cut-off points were applied. Advanced maternal age was the only risk factor studied that was modified by race/ethnicity, with non-Hispanic white and Hispanic women being more adversely affected than other racial/ethnic groups. CONCLUSIONS Overweight/obesity, advanced maternal age, family history of type 2 diabetes, and foreign-borne status are important risk factors for GDM. The relative contributions of these risk factors differ by race/ethnicity, mainly due to differences in population prevalence of these risk factors.

Racial/Ethnic Differences in Hypertension Prevalence, Treatment, and Control for Outpatients in Northern California 2010–2012

BACKGROUND Hypertension (HTN) is a known major cardiovascular disease risk factor, but prevalence, treatment, and control of HTN among rapidly growing minority groups such as Asian Americans and Hispanics are unknown largely due to either underrepresentation in epidemiologic studies or aggregation of Asian American subgroups. METHODS A three-year cross-section (2010-2012) of patients from a large ambulatory care setting in northern California was examined in the following subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Mexicans, non-Hispanic Blacks (NHBs), and non-Hispanic Whites (NHWs). We defined HTN as two separate nonemergent office visit blood pressure measurements ≥140/90 mm Hg, physician diagnosis of HTN, or use of antihypertensive medications. RESULTS A total of 208,985 patients were included in the study. Age-adjusted HTN prevalence ranged from 30.0% in Chinese women to 59.9% in Filipino men. Most minority subgroups had lower or similar odds of having HTN compared with NHWs, except for Filipinos and NHBs whose odds were significantly higher after adjusting for patient demographic and clinical characteristics. Asian Americans and NHBs were more likely to be treated for HTN compared with NHWs. Achievement of blood pressure control was lower among Filipino women (odds ratio = 0.82, 99% confidence interval 0.70-0.96) and NHB men (odds ratio = 0.73, 99% confidence interval 0.58-0.91), compared with NHW women and men. CONCLUSIONS Substantial racial/ethnic variation in HTN prevalence, treatment, and control was found in our study population. Filipino and NHB women and men are at especially high risk for HTN and may have more difficulty in achieving adequate blood pressure control.

Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association

Background and Purpose: Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management. Method: The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention. Results: The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment. Conclusions: The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.

Comparative effectiveness of early versus delayed metformin in the treatment of type 2 diabetes

AIM The purpose of this study was to evaluate the effectiveness of early versus delayed initiation of metformin in type 2 diabetes. METHODS We identified 2925 new users of metformin with type 2 diabetes between 2005 and 2012 in the electronic health records of an integrated health system in Northern California. Patients were matched 1:1 on the propensity for receiving early treatment (defined as ≤6 months from first evidence of diabetes). We evaluated the effectiveness of early versus delayed metformin treatment on intermediate clinical outcomes indicated by changes in hemoglobin A1c (HbA1c) and body mass index (BMI), as well as the incidence of therapy intensification (addition or substitution of a second antihyperglycemic agent). RESULTS A total of 2144 propensity-score matched patients were included in the early or delayed treatment group (n=1072, in each). Early treatment was associated with significantly larger decreases in HbA1c (-0.36%; 95% confidence intervals [CI]: -0.44 to -0.27%; P<0.001) and BMI (-0.46 kg/m(2); 95% CI: -0.64 to -0.29 kg/m(2); P<0.001) relative to delayed treatment. Patients receiving early treatment also had a greater likelihood of attaining an HbA1c<7% (<53 mmol/mol) (odds ratio: 2.00; 95% CI: 1.63-2.45; P<0.001) and a reduced risk of therapy intensification (hazard ratio: 0.72; 95% CI: 0.61-0.85; P<0.001). CONCLUSIONS Treatment with metformin earlier in the course of type 2 diabetes is associated with better glycemic control, more pronounced weight reduction, and a lower risk for therapy intensification than delayed treatment. Antihyperglycemic therapy should be initiated early after diagnosis to achieve optimal outcomes.

Dyslipidemia in Special Ethnic Populations

This article reviews racial/ethnic differences in dyslipidemia-prevalence of dyslipidemia, its relation to coronary heart disease (CHD) and stroke mortality rates, response to lipid-lowering agents, and lifestyle modification. Asian Indians, Filipinos, and Hispanics are at higher risk for dyslipidemia, which is consistent with the higher CHD mortality rates in these groups. Statins may have greater efficacy for Asians, but the data are mixed. Lifestyle modifications are recommended. Culturally-tailored prevention and intervention should be provided to the minority populations with elevated risk for dyslipidemia and considerably more research is needed to determine the best approaches to helping specific subgroups.

Clocks Moving at Different Speeds: Cultural Variation in the Satisfaction With Wait Time for Outpatient Care.

Objective:To explore racial/ethnic differences in satisfaction with wait time of scheduled office visits by comparing electronic health record (EHR)-based, patient-reported, and patient satisfaction with wait time Study Setting:A large multispecialty ambulatory care organization in Northern California. Patient experience surveys were collected between 2010 and 2014. Surveys were mailed after randomly selected nonurgent visits. Returned survey data were linked to EHR data for surveyed visits. Study Design:Observational, retrospective study designed to assess differences in patient-reported wait time, wait-time satisfaction, and actual EHR-recorded wait time with respect to self-reported race/ethnicity. Multivariate regression models with provider random effects were used to evaluate differences. Results:Asian subgroups (Chinese, Asian Indian, Filipino, Japanese, Korean, and Vietnamese) and Latinos gave poorer ratings for wait time than non-Hispanic whites (NHWs). The average wait time reported by Asians was longer than that reported by NHWs. On the basis of EHR data, however, no minority group was likely to wait longer, and all, except for Japanese (10%), were more likely to be late for the appointment (16%: Filipino and 23%: Asian Indian), than NHWs (13%). Conclusions:Given actual wait times, Asians perceive longer wait time and were less satisfied with wait times. Asians may have different expectations about wait time at the clinic.