Association Between Socioeconomic Status and Mortality, Cardiovascular Disease, and Cancer in Patients With Type 2 Diabetes

Abstract

IMPORTANCE The association between socioeconomic status and survival based on all-cause, cardiovascular (CV), diabetes-related, and cancer mortality in type 2 diabetes has not been examined in a setting of persons with equitable access to health care with adjustment for important confounders. OBJECTIVE To determine whether income, educational level, marital status, and country of birth are independently associated with all-cause, CV, diabetes-related, and cancer mortality in persons with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS A study including all 217 364 individuals younger than 70 years with type 2 diabetes in the Sweden National Diabetes Register (January 1, 2003, to December 31, 2010) who were monitored through December 31, 2012, was conducted. A Cox proportional hazards regression model with up to 17 covariates was used for analysis. MAIN OUTCOMES AND MEASURES All-cause, CV, diabetes-related, and cancer mortality. RESULTS Of the 217 364 persons included in the study, mean (SD) age was 58.3 (9.3) years and 130 839 of the population (60.2%) was male. There were a total of 19 105 all-cause deaths with 11 423 (59.8%), 6984 (36.6%), and 6438 (33.7%) CV, diabetes-related, or cancer deaths, respectively. Compared with being single, hazard ratios (HRs) for married individuals, determined using fully adjusted models, for all-cause, CV, and diabetes-related mortality were 0.73 (95% CI, 0.70-0.77), 0.67 (95% CI, 0.63-0.71), and 0.62 (95% CI, 0.57-0.67), respectively. Marital status was not associated with overall cancer mortality, but married men had a 33% lower risk of prostate cancer mortality compared with single men, with an HR of 0.67 (95% CI, 0.50-0.90). Comparison of HRs for the lowest vs highest income quintiles for all-cause, CV, diabetes-related, and cancer mortality were 1.71 (95% CI, 1.60-1.83), 1.87 (95% CI, 1.72-2.05), 1.80 (95% CI, 1.61-2.01), and 1.28 (95% CI, 1.14-1.44), respectively. Compared with native Swedes, HRs for all-cause, CV, diabetes-related, and cancer mortality for non-Western immigrants were 0.55 (95% CI, 0.48-0.63), 0.46 (95% CI, 0.38-0.56), 0.38 (95% CI, 0.29-0.49), and 0.72 (95% CI, 0.58-0.88), respectively, and these HRs were virtually unaffected by covariate adjustment. Hazard ratios for those with a college/university degree compared with 9 years or less of education were 0.85 (95% CI, 0.80-0.90), 0.84 (95% CI, 0.78-0.91), and 0.84 (95% CI, 0.76-0.93) for all-cause, CV, and cancer mortality, respectively. CONCLUSIONS AND RELEVANCE Independent of risk factors, access to health care, and use of health care, socioeconomic status is a powerful predictor of all-cause and CV mortality but was not as strong as a predictor of death from cancer.

Risk of dying from cancer by socio-demographic indicators in the Slovak Republic

“…Surprisingly, in the Czech Republic, divorce considered as a psychological factor was significant factor in explaining cancer mortality, when for every 1% increase in the level of divorce, mortality is expected to increase by 0.27% (19). In a recent study about cancer mortality in Swedish persons with diabetes mellitus type 2, marital status was not associated with overall cancer mortality, however, married men reported a 33% lower risk of prostate cancer mortality compared to single men (20).…”

Development and Performance of Text-Mining Algorithms to Extract Socioeconomic Status From De-Identified Electronic Health Records

“…SES has been consistently associated with health outcomes such as mortality, cancer, and cardiovascular disease 27,28 . Despite these consistent associations, SES data are typically not included in genetic studies of health outcomes.…”

Social disparities in diabetes care: a general population study in Denmark

“…However, trends have been reported less favorable among patients with low SES even in countries with equal access to health care [3,4]. Associations between low SES and mortality in patients with T2DM have not been fully explained [5,6]. Reduced survival could be imputed to differences in the attainment of treatment goals and a lower level of pharmacotherapy among patients with low SES [6].…”

“…Associations between low SES and mortality in patients with T2DM have not been fully explained [5,6]. Reduced survival could be imputed to differences in the attainment of treatment goals and a lower level of pharmacotherapy among patients with low SES [6]. Patients with low SES may have difficulty bearing the costs of the multidrug regimens in T2DM [7], and medication adherence in general has been reported to be influenced by SES [7–9].…”