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Table 2 Characteristics of the studies

From: Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review

Reference - Country Assessment of individual level socio-economic status (SES) Assessment of regional deprivation Main results Main conclusion
- n
-% women
- type of diabetes
- age (years)
  1 2 3 4 5
Arday D.R. et al. [19] - USA ZQ score (household income; education; occupation; home value) - HbA1c tests (sign.), eye examinations (sign.) and lipid profile measurements (sign.) less likely for patients living in the most deprived regions - Worse diabetes care in the most deprived states
- n = 1,941,517
- 54.4%
- T1D + T2D - Substantial reduction in variation between states concerning diabetes care after adjustment for residents’ characteristics (ZQ score)
- 18–75
- 67.5 (median)
Bachmann M.O. et al. [20] - UK Educational level, individual income - Higher HbA1c values (sign.), more non-compliance (sign.), retinopathy (trend) and less hospital attendance (sign.) among patients with low education - Larger burden of morbidity for patients with low SES, but less hospital care
- n = 555
- 47%
- T1D + T2D
- 65 (mean)
- More complications among patients with low education and low income (sign.)
- More negative effects on social life (sign.) and personal life (sign.) among patients with low education and low income
Bäz L. et al. [21] - Germany Index based on educational level, occupational status and income - Increasing HbA1c (sign.) and BMI (sign.) with decreasing SES - Worse diabetes control for patients with low SES
- n = 555 - No sign. association between BP and SES
- 50.2% (T1D)
45.5% (T2D)
- T1D + T2D
- 56.1 (mean)
Bebb C. et al. [22] - UK Townsend score - Higher HbA1c values for patients living in the most deprived regions (sign.) and for practices with many patients living in the most deprived regions (sign.) - Worse glycaemic control in the most deprived regions
- n = 1,534
- 41%
- T2D - Effect of regional deprivation most important for extreme deprivation
- 18–80
66.2 (median)
     - Variation between practices concerning HbA1c values largely explained by percentage of patients living in the most deprived regions  
  1 2 3 4 5
Bihan H. et al. [23] - France EPICES score - Higher HbA1c values (sign.), more complications such as retinopathy (sign.) and neuropathy (sign.) and fewer 1-day hospitalizations (sign.) in patients with low SES - Worse glycaemic control and more microvascular complications in patients with low SES
- n = 135
- 48.8%
- T1D + T2D
- 59 (mean)
Bottle A. et al. [24] - UK IMD - Age group 25–59 years: higher total hospital (sign.) and ketoacidosis admission rates (sign.) for patients living in the most deprived regions - Worse diabetes control, more hospital admissions and lower quality of health care in the most deprived regions
- n = 1,760,898
- (unknown)
- T1D + T2D;
- 25–59 - Age group ≥60 years: higher total hospital admission rates (sign.), lower total quality score (not sign.) and lower HbA1c control score (not sign.) for patients living in the most deprived regions
25–59 (main group, 47.9%)
Brown A.F. et al. [25] - USA Educational level, income - Small SES differences concerning six out of seven process indicators, i.e. lipid profile measurement, foot examination, aspirin advice or use, influenza vaccination (all not sign.) and in two out of three intermediate outcomes, i.e. HbA1c control (not sign.) and LDL control (sign.) - Worse diabetes control for patients with low SES concerning glycaemic control and dilated eye examinations
- n = 7,456
- 53%
- T1D + T2D
- 60.4 (mean)
- Higher HbA1c values (sign.) and fewer dilated eye examinations (sign.) in low SES group
Geraghty E.M. et al. [26] - USA Differences by income, educational level, unemployment (GIS analyses) - Higher HbA1c values for patients living in more deprived regions (not sign.) - Tendency for worse glycaemic control in most deprived regions
- n = 7.288
- 47.4%
- T1D + T2D - No association between regional deprivation and LDL control
- 62 (mean)
Gnavi R. et al. [27] - Italy Educational level, income - Fewer measurements of HbA1c (not sign.) and eye examinations (not sign.) among patients with low education - Most SES differences not statistically significant
- n = 33,453 - SES differences in health care processes favouring the disadvantaged group
- 49.4% - Fewer ECG measurements (not sign.) and visits to diabetologists (not sign.) among patients with low education or low income
- T1D + T2D
- 65–74
  65–75 (main group 34.3%)     
  1 2 3 4 5
Gray J. et al. [28] - UK IMD - Small difference concerning health care process between most and least deprived regions - Tendency for worse health care in the most deprived regions
- n = 6,035
- Higher values of HbA1c (not sign.) and BP (not sign.) for patients living in the most deprived regions
- 48.3%
- T1D + T2D
- 65–74 (main group, 26.6%)
Guthrie B. et al. [29] - UK Carstairs deprivation score - Less complete process indicators of good quality health care for patients living in the most deprived regions (sign.) - No consistent association between quality of care and regional deprivation
- n = 10,191
- 47.1%
- T2D
- 67.8 (median)
- Higher percentage of smokers for patients living in the most deprived regions (sign.)
Hippsley-Cox J. et al. [30] - UK Townsend score - Higher BMI (sign.), more smokers (sign.), less neuropathy (sign.), microalbuminuria (sign.) and eye examinations (sign.), fewer flu vaccinations for patients living in the most deprived regions - Worse process of care and worse outcomes in the most deprived regions
- n = 53,678
- (unknown)
- T1D + T2D
- >16
- Higher HbA1c values (sign.) and BP values (sign.)
Hsu C.C. et al. [31] - Taiwan Income - More severe diabetes symptoms (sign.), fewer visits to diabetes clinic (sign.) and to ambulatory diabetes clinic (sign.) in low SES group - Higher probability of hospital-diagnosed diabetes following severe symptoms and smaller likelihood of receiving recommended diabetes check-ups for patients with low SES
- n = 1,462
- 39.3–50.4%
- T2D
- > 20
  - Fewer tests for HbA1c (sign.), LDL (sign.), triglycerides (sign.) and fewer examinations for retinopathy (sign.) in low SES group
Icks A. et al. [32] - Germany Helmert index (based on educational level, occupational status, income) - Unfavourable process (retinopathy screening, foot examination, diabetes education, lipid and BP control, all not sign.) and outcome (HbA1c, not sign.) indicators in low SES group - Preliminary indications of less than good health care especially for patients with low SES
  - n = 149
  - 46% - Less knowledge about the term ‘HbA1c’ in low SES group (sign.)
  - T2D
  - 62 (mean)     
  1 2 3 4 5
James G.D. et al. [33] - UK Townsend score - Higher values of HbA1c in most deprived regions (sign.) - Worse glycaemic control in deprived regions, independent of other social factors such as ethnicity
- n = 24,111
- 47%
- T2D
- 52.6 (median)
Larranaga et al. [34] - Spain Index from Basque Institute of Statistics - Higher values of LDL (sign.) and HbA1c (sign.) in most deprived regions - Worse health care and higher prevalence of clinical complications in most deprived regions
- n = 2,985
- 52%
- T2D - Higher risk of macroangiopathy complications (sign.) and higher risk of retino-, neuro- and nephropathy (not sign.) in most deprived regions
- ≥ 24
- More consultations per year in most deprived regions (sign.)
Millet C. et al. [35] - UK IMD - Lower rates of reaching health care targets concerning HbA1c, BP and cholesterol in most deprived regions - Worse intermediate outcomes in most deprived regions
- n = 1,852,762
- unknown
- T1D + T2D
- > 18
Reisig V. et al. [36] - Germany Helmert index (based on educational level, occupational status, income) - Among patients with T2DM and myocardial infarction: lower probability of reaching HbA1c target (sign.) and higher prevalence of retinopathy (sign.) in low SES group - Worse glycaemic control and more complications for patients with low SES
- n = 373
- 31.9%
- T2D
- 68.1 (median)
Shani M. et al. [37] - Israel Income - Lower probability of reaching HbA1c target (sign.) and LDL target (sign.) in low SES group - Worse glycaemic control for patients with low SES
- n = 18,316
- 50.3%
- T1D + T2D
  - 65.5 (median)     
  1 2 3 4 5
Wilf-Miron R. et al. [38] - Israel Ranking based on educational level, employment, income, housing density - ‘Optimal follow-up’ (sign.) is more likely in most deprived regions - Process indicators: better health care quality in the most deprived regions
- n = 74,953
- 46.1%
- T1D + T2D - Appropriate LDL control (not sign.) and achieving HbA1c target (sign.) less likely in most deprived regions - Intermediate outcome indicators: worse health care quality in the most deprived regions
- 59 (mean)
Wong K.W. et al. [39] - China Fee for service waiver (yes/no) - Recording of cholesterol (sign.) and of BMI (sign.), screening for nephropathy (sign.) and retinopathy (sign.) less likely in low SES group - Process indicators: worse health care for patients with low SES
- n = 1,970 - Achievement of BP target (sign.) and HbA1c target (not sign.) less likely in low SES group - Intermediate outcome indicators: worse health care for patients with low SES
- 55.1%
- T2D
- 63.2 (median)
  1. Sign.: 5% level.
  2. T1D, Type 1 diabetes.
  3. T2D, Type 2 diabetes.