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Original Investigation |

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

Araz Rawshani, MD, PhD1,2; Ann-Marie Svensson, PhD2,3; Björn Zethelius, MD, PhD4,5; Björn Eliasson, MD, PhD1,3; Annika Rosengren, MD, PhD1,2; Soffia Gudbjörnsdottir, MD, PhD2,3
[+] Author Affiliations
1Institute of Medicine, Department of Clinical and Molecular Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
2National Diabetes Register, Centre of Registers, Gothenburg, Sweden
3Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
4Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
5Medical Products Agency, Section for Epidemiology, Uppsala, Sweden
JAMA Intern Med. 2016;176(8):1146-1154. doi:10.1001/jamainternmed.2016.2940.
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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.

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Figure 1.
Adjusted Hazard Ratios (HRs) for Death From Any Cause

Model 1 was identical for all outcomes and included age, sex, duration of diabetes, marital status, income, educational level, and country of birth. Model 2 was further adjusted for smoking, hemoglobin A1c level, estimated glomerular filtration rate, diabetes treatment, and body mass index. Model 3 was further adjusted for albuminuria, heart failure, myocardial infarction, stroke, stage 5 chronic kidney disease, and cancer at baseline.

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Figure 2.
Adjusted Hazard Ratios (HRs) for Death From Cardiovascular Causes

Model 1 was identical for all outcomes and included age, sex, duration of diabetes, marital status, income, educational level, and country of birth. Model 2 was further adjusted for smoking, hemoglobin A1c level, estimated glomerular filtration rate, diabetes treatment, and body mass index. Model 3 was further adjusted for albuminuria, heart failure, myocardial infarction, stroke, and stage 5 chronic kidney disease.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Adjusted Hazard Ratios (HRs) for Death From Cancer

Model 1 was identical for all outcomes and included age, sex, duration of diabetes, marital status, income, educational level, and country of birth. Model 2 was further adjusted for smoking, hemoglobin A1c level, estimated glomerular filtration rate, diabetes treatment, and body mass index. Model 3 was further adjusted for albuminuria, heart failure, myocardial infarction, stroke, stage 5 chronic kidney disease, and cancer at baseline.

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