ArticlesEnhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial
Introduction
Patients of south Asian ethnic background (UK decennial census categories Indian, Pakistani, Bangladeshi, and other Asians) with type 2 diabetes present special management challenges.1, 2 In the UK, prevalence of type 2 diabetes is four-fold to six-fold higher in people from south Asia than in white Europeans.3 Furthermore, onset can be more than a decade earlier and the risk of cardiovascular and renal complications greater in patients from south Asia, with higher morbidity and 50% higher mortality.4 Health-care delivery in this population is more challenging because of cultural, communication, and comprehension difficulties, which along with social deprivation further complicate the achievement of defined targets.5, 6 Payments for UK general practices based on their achievement of quality (quality and outcomes framework [QOF])7 targets do not distinguish different ethnic groups.
Enhanced care packages based in the community have been associated with improved metabolic outcomes in some ethnic groups8 but have not been fully assessed in large randomised controlled trials. Such trials are scarce in people of south Asian ethnic origin.9 The United Kingdom Asian Diabetes Study (UKADS) assessed a community-based complex intervention that aimed to reduce cardiovascular risk in south Asian people with type 2 diabetes. The intervention package was tailored to the needs of the south Asian community and consisted of additional time with a practice nurse, Asian link workers, and input from diabetes-specialist nurses, who were working to protocols to achieve clearly defined targets. The UKADS study hypothesis was that an enhanced care package for diabetes would improve cardiovascular risk profile in patients of south Asian origin, with established type 2 diabetes.
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Study design and patients
In line with recognised complex intervention evaluations10 and following a protocol informed by a pilot study,11 we undertook a large cluster randomised controlled trial from March, 2004 to April, 2007. 21 general practices (seven in Coventry [500 patients] and 14 in Birmingham, UK [986 patients]) with a very high proportion (more than 80%) of south Asian patients were included in this cluster randomised controlled trial. Between March 2004 and April 2005, nine practices were randomised to
Results
The figure shows the trial profile. 1486 patients of south Asian ethnic origin, with established type 2 diabetes, consented to take part and were included in the study; 500 (34%) from Coventry and 986 (66%) from Birmingham.
Table 2 shows the baseline risk-factor profile for the intervention and control groups. Mean age for the whole group was 57·0 (SD 11·9) years. Differences observed between groups for sex, age, duration of diabetes, and treatment for diabetes were not significant. The
Discussion
Our results confirm that the achievement of targets set by national and international advisory bodies poses a major challenge for south Asian ethnic groups in inner-city general practices.12, 13, 14, 21 At baseline, many of our patients had haemoglobin A1c greater than 7%, blood pressure greater than 130/80 mm Hg, and total cholesterol greater than 4 mmol/L, which are higher than targets recommended by international standards for diabetes care. After 2 years in which secular changes included
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