Introduction: Evidence suggests that clinicians may view or label patients as nonadherent in a biased manner. Therefore, we performed a retrospective cohort analysis exploring associations between patient demographics and zip code-level income with the International Classification of Diseases, Tenth Version (ICD-10) diagnoses for nonadherence among type 2 diabetes mellitus (T2DM) patients, comparing primary and specialty care settings. Providers in the primary care group included internal medicine and family medicine physicians. In the specialty care group, providers included endocrinologists and diabetologists only. Methods: Participants were identified from 5 primary care and 4 endocrinology sites in the University of Pennsylvania Health System between January 1, 2015, and January 1, 2019. Demographics, hemoglobin A1c (HbA1c), and ICD-10 codes for T2DM and nonadherence were extracted from the electronic health record and analyzed in October 2019. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, insurance, and zip code-level median household income, controlling for patient characteristics and HbA1c as a proxy for diabetes self-management. Results were compared between primary and specialty care sites. Results: A total of 6072 patients aged 18–70 years were included in this study. Black race, Medicare, and Medicaid were associated with increased nonadherence labeling while controlling for patient characteristics ([ARR = 2.48, 95% CI: 2.01, 3.04], [ARR = 1.82, 95% CI: 1.50, 2.18], [ARR = 1.61, 95% CI: 1.32, 1.93], respectively). The results remained significant on adjustment with zip code-level income and showed no differences between primary and specialty sites. Lower-income zip codes showed a significant association with increased rates of nonadherence labeling. Conclusions: Black race, non-private insurance, and lower-income zip codes were associated with disproportionately high rates of nonadherence labeling in both primary and specialty management of T2DM, possibly suggestive of racial or class bias.

中文翻译：

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种族、保险和邮政编码级别的收入与初级和专科糖尿病护理中的非依从性诊断的关联

介绍：有证据表明，临床医生可能会以有偏见的方式将患者视为或标记为不依从。因此，我们进行了一项回顾性队列分析，探讨了患者人口统计学和邮政编码级别收入与国际疾病分类第十版 (ICD-10) 对 2 型糖尿病 (T2DM) 患者不依从性的诊断之间的关联，比较了原发性和专科性护理设置。初级保健组的提供者包括内科医师和家庭医学医师。在专业护理组中，提供者仅包括内分泌学家和糖尿病学家。方法：参与者是在 2015 年 1 月 1 日至 2019 年 1 月 1 日期间从宾夕法尼亚大学卫生系统的 5 个初级保健机构和 4 个内分泌学站点中确定的。2019 年 10 月，从电子健康记录中提取了 T2DM 和不依从性的 ICD-10 和 ICD-10 代码并进行了分析。使用对数二项式回归模型来估计患者按种族、保险和邮政编码级别的家庭收入中位数不依从性标签的风险，控制患者特征和 HbA1c 作为糖尿病自我管理的代理。结果在初级和专科护理站点之间进行了比较。结果：本研究共纳入 6072 名 18-70 岁的患者。在控制患者特征的同时，黑人、医疗保险和医疗补助与不依从性标签增加相关（[ARR = 2.48, 95% CI: 2.01, 3.04], [ARR = 1.82, 95% CI: 1.50, 2.18], [ARR = 1.61, 95% CI：分别为 1.32, 1.93])。结果在调整邮政编码级别的收入时仍然显着，并且在主要站点和专业站点之间没有差异。低收入邮政编码与不遵守标签率的增加有显着关联。结论：黑人种族、非私人保险和低收入邮政编码与 T2DM 的初级和专业管理中不成比例的高不依从标签率相关，可能暗示种族或阶级偏见。