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An observational study of socioeconomic and clinical gradients among diabetes patients hospitalized for avoidable causes: evidence of underlying health disparities in China?

Brian Chen1*, Karen Eggleston2, Hong Li3, Nilay Shah4 and Jian Wang5

Author Affiliations

1 Arnold School of Public Health, University of South Carolina, 800 Sumter St, Columbia, SC 29208, USA

2 Walter A. Shorenstein Asia Pacific Research Center, Stanford University, 616 Serra St., Encina Hall E311, Stanford, CA 94305, USA

3 Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, Zhejiang 310016, China

4 Division of Health Care Policy and Research, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA

5 Center for Health Policy and Management, Shandong University, Jinan, Shandong 250012, China

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International Journal for Equity in Health 2014, 13:9  doi:10.1186/1475-9276-13-9

Published: 30 January 2014



Diabetes is an ambulatory care sensitive condition that can generally be managed in outpatient settings with little or no need for inpatient care. As a preliminary step to investigate whether health disparities can be detected in the inpatient setting in China, we study how diabetic patients hospitalized without prior primary care contact or with greater severity of illness differ from other diabetic inpatients along socioeconomic and clinical dimensions.


We conduct an observational study using three years of clinical data for more than 1,800 adult patients with diabetes at two tertiary hospitals in East China. Univariate analysis and probit regression are used to characterize the differences in socioeconomic and clinical factors between patients hospitalized for diabetes with no prior primary care contact and those hospitalized with previous treatment experience. Secondarily, we use ordinary least squares regression to estimate the socioeconomic and clinical differences associated with poor serum glucose control at admission.


We find that compared with patients hospitalized after prior treatment experience, inpatients with no previous primary care contact for diabetes have worse clinical laboratory values, are more likely to be young and male, to have lower education attainment, and to have poorer blood sugar control. Insurance, urban residence, and previous use of diabetic medication are in turn negatively correlated with HbA1c levels upon admission.


Among hospitalized diabetic patients, socioeconomic factors such as lower education attainment, rural residence and lack of full insurance are associated with avoidable hospitalizations or worse indicators of health. Although we cannot definitively rule out selection bias, these findings are consistent with health disparities observable even at the inpatient level. Future studies should study the underlying mechanism by which traditionally vulnerable groups are more likely to be hospitalized for avoidable causes and with greater severity of illness.

Diabetes; China; Equity; Social gradient; Preventable hospitalizations; Ambulatory care sensitive conditions