We interviewed 676 patients who identified themselves as Caucasian (34%), African American (41%), or Latino (25%) (). Latino patients were significantly younger (mean age 55 years vs. 65 years for African Americans and Caucasians; P < 0.01), more likely to have been born outside the U.S. (64% vs. 1 and 7%, respectively; P < 0.01), and less likely to have completed high school (50% vs. 73 and 84%, respectively; P < 0.01). Half of the interviews with Latinos were conducted in Spanish. The overall study population was well insured with over half of the patients having some form of private insurance and >90% of patients having a prescription drug plan.
Demographics and clinical characteristics by race/ethnicity among adults with type 2 diabetes in Chicago-area clinics, 2004–2006
There was no significant difference in the mean duration of diabetes across ethnic groups (9–10 years). However, there were differences in the prevalence of comorbid conditions or complications across ethnic groups. Latinos had less self-reported hypertension than African Americans and Caucasians, but there was no difference in prevalence of hypercholesterolemia. African Americans had higher rates of self-reported diabetes complications such as eye disease, heart disease, and stroke, whereas Latinos had the lowest rates. For overall health status, Latinos had higher mean physical component summary scores than the other ethnic groups but lower mental component summary scores.
Mean A1C levels were higher for African Americans (7.54%) and Latinos (7.69%) than for Caucasians (7.18%) (P < 0.01); consistent with these differences, lower proportions of African Americans (41%) and Latinos (47%) had A1C levels <7% than of Caucasians (55%) (P < 0.01). With regard to cholesterol control, Latinos also had the highest mean LDL cholesterol levels (102 vs. 95 mg/dl) and the lowest proportion of patients with LDL cholesterol levels <100 mg/dl (56 vs. 63%) of the three racial/ethnic groups (P < 0.01). The picture was reversed in the case of blood pressure control in that Latinos had the lowest mean systolic blood pressure levels (126 mg/dl) of the three groups, whereas African Americans had the highest (136 mg/dl) (P < 0.01).
Consistent with our findings related to risk factor levels, Latinos had the lowest use of medications among the three racial/ethnic groups: the lowest mean number of both total medications and diabetes-related medications (three vs. four medications for African Americans and Caucasians; P < 0.01). In terms of intensity of glucose control regimen, Latinos also had the lowest percentage of insulin use (18%), whereas African Americans had the highest use of insulin (27%) (P < 0.01). Similarly, Latinos had the lowest percentage of aspirin prophylaxis use (24 vs. 47% for Caucasians) and cholesterol-lowering drug use (51 vs. 68% for Caucasians; both P < 0.01). Frequently used nondiabetes medications included multivitamins, proton-pump inhibitors, calcium supplementation, and thyroid replacement therapy.
In direct questions regarding concerns for medications, both African Americans and Latinos had significantly more concerns about various elements of medication-taking than Caucasians (). They were more likely to say that they worried about side effects (African Americans 49% and Latinos 66% vs. Caucasians 39%), development of dependency on medications (52% and 65% vs. 39%, respectively), and the potential harms of generic substitutes (35 and 26% vs. 13%, respectively; all P < 0.01). Three-quarters of Latinos had concerns about the costs of medications compared with one-half of African Americans and Caucasians (P < 0.01). With regard to the implications of future changes to medication regimens, African Americans and Latinos were also more likely to report that changes in their medication regimen would represent a disruption in their daily routine and would raise concerns about their health.
Differences in medication concerns and perceptions of future medications by race/ethnicity among adults with type 2 diabetes in Chicago-area clinics, 2004–2006*
When we directly queried patients about their willingness to adopt more medications, we found significant differences across racial/ethnic groups. More African Americans (18%) and Latinos (12%) than Caucasians would be opposed to the addition of more medications if recommended by their physician (7%) (P < 0.01), although the majority of patients in all groups would accept such changes in their medications. When asked about the possibility of adding insulin (among those not using insulin), the proportion of patients opposed to such a change was larger than the proportion opposed to the general addition of more medications. As observed with the prior question, larger proportions of African Americans (26%) and Latinos (22%) than Caucasians (17%) were opposed to the addition of insulin to their regimens (P = 0.09), although this difference did not reach statistical significance.
The majority of these unadjusted racial/ethnic differences in medication concerns were attenuated by adjustment for socioeconomic, demographic, and clinical covariates but remained significant (). For example, the association between race/ethnicity and side effect concerns became less pronounced in adjusted analysis (for Latinos, unadjusted odds ratio (OR) 3.00 [95% CI 1.98–4.55] → adjusted OR 2.92 [1.83–4.64]). With regard to responses to questions regarding the addition of more medications, African Americans remained significantly more likely to express a reluctance to add new medications than Caucasians (unadjusted OR 3.05 [1.66–5.61] → adjusted OR 2.53 [1.35–4.72]) even after adjustment for socioeconomic, demographic, and clinical covariates. Latino-Caucasian differences in opinion were borderline in significance in unadjusted analysis (1.95 [0.97–3.93]) and became clearly nonsignificant (1.48 [0.69–3.15]) when accounting for covariates.
Adjusted analyses of concerns about medications by race/ethnicity, adjusted comparisons in adults with type 2 diabetes from Chicago-area clinics, 2004–2006*
In our comprehensive analysis of predictors of a reluctance to add medications, we found that concerns about growing dependent on medications, report of unpleasant or painful experience with medications, anticipated disruption of daily routine, concerns regarding health if faced with medication changes, and concerns over switches from brand-name to generic drugs were all significantly associated with a reluctance to add more medications (all P < 0.01). The patient's physical health status, current number of medications, and current number of diabetes-related medications were not significantly associated with a reluctance to add more medications. Higher mental health status was associated with a lower likelihood of opposing additional medications (P < 0.01). After identification and exclusion of collinear variables, the final model of a reluctance to add more medications included report of unpleasant or painful experience with medications (OR 2.43 [95% CI 1.39–4.27]; P < 0.01) and anticipated disruption of daily routine (1.97 [1.14–3.42]; P = 0.02). African American race remained a significant predictor of reluctance to add more medications even within the fully adjusted model (2.48 [1.32–4.69]; P < 0.01).