Socioeconomic status impacts cardiovascular outcomes in diabetes

By Eleanor McDermid

Patients with Type 2 diabetes are at a particularly high risk of adverse cardiovascular outcomes if they have low socioeconomic status, a registry study from Sweden shows.

Lead researcher Araz Rawshani (Sahlgrenska University Hospital, Gothenburg) and colleagues describe the Swedish healthcare system as "arguably one of the most equitable" in the world.

Their findings are therefore "likely to present the influence of socioeconomic variables independent of their effect on health care use and access", they write in JAMA Internal Medicine.

During up to 10 years of follow-up, there were 19,105 all-cause deaths among 217,364 Type 2 diabetes patients (average age 58.3 years) in the Sweden National Diabetes Register. Of these deaths, 59.8% were related to cardiovascular conditions, 36.6% to diabetes and 33.7% to cancer.

Unadjusted mortality rates rose with declining income, from 8.92 deaths per 1000 person-years among patients in the highest income quintile to 18.33 deaths per 1000 person-years among those in the lowest quintile. The same was true for cardiovascular mortality, with corresponding rates of 4.72 and 11.15 per 1000 person-years, but there was little effect on cancer mortality.

The influence of socioeconomic status remained after accounting for variables including age, smoking, diabetes duration and treatment, education, body mass index and cardiovascular comorbidities. All-cause mortality was a significant 1.71-fold more likely to occur among patients in the bottom versus the top income quintiles and cardiovascular mortality was 1.87-fold more likely.

Years of education had a significant protective effect against both all-cause and cardiovascular mortality, and high income and more education were both protective against cancer death, although to a smaller extent than against cardiovascular mortality.

"The fact that controlling for risk factors and covariates did not eliminate the effect of socioeconomic indicators does not imply that risk factor control is ineffective in reducing these disparities", caution the researchers.

They suggest that "socioeconomically tailored management and aggressive treatment" of cardiovascular risk factors could counter the effects of socioeconomic status on cardiovascular death, with an expected effect on cancer death as well, because of overlapping risk factors.

Source: JAMA Intern Med 2016; Advance online publication

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