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

Dahai Yu,1,2 Uchechukwu Levi Osuagwu,3,4 Karen Pickering,5 John Baker,5,6 Richard Cutfield,5,7 Zheng Wang,1 Yamei Cai,1,* Brandon J Orr-Walker,5,6 Gerhard Sundborn,8 Zhanzheng Zhao,1,* David Simmons1,3,4,* 1Department of Nephrology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, People’s Republic of China; 2Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK; 3Translational Health Research Institute (THRI), Western Sydney University, Sydney, NSW, Australia; 4School of Medicine, Western Sydney University, Sydney, NSW, Australia; 5Diabetes Foundation Aotearoa, Auckland, New Zealand; 6Department of Diabetes and Endocrinology, Counties Manukau Health, Auckland, New Zealand; 7Department of Diabetes and Endocrinology, Waitemata District Health Board, Auckland, New Zealand; 8Section of Pacific Health, The University of Auckland, Auckland, New Zealand*These authors contributed equally to this workCorrespondence: David Simmons; Zhanzheng Zhao, Department of Nephrology, The First Affiliated Hospital Zhengzhou University, Zhengzhou, 450052, People’s Republic of China, Tel +61 2 4620 3899 ; +86 139 3852 5666, Fax +61 2 4620 3890 ; +86 371 6698 8753, Email Da.Simmons@westernsydney.edu.au; zhanzhengzhao@zzu.edu.cnPurpose: 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