摘要：Objectives. We explored whether and how race shapes perceived health status in patients with type 2 diabetes mellitus and coronary artery disease. Methods. We analyzed self-rated health (fair or poor versus good, very good, or excellent) and associated clinical risk factors among 866 White and 333 Black participants in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. Results. Michigan Neuropathy Screening Instrument scores, regular exercise, and employment were associated with higher self-rated health ( P < .05). Blacks were more likely than were Whites to rate their health as fair or poor (adjusted odds ratio [OR] = 1.88; 95% confidence interval [CI] = 1.38, 2.57; P < .001). Among Whites but not Blacks, a clinical history of myocardial infarction (OR = 1.61; 95% CI = 1.12, 2.31; P < .001) and insulin use (OR = 1.62; 95% CI = 1.10, 2.38; P = .01) was associated with a fair or poor rating. A post–high school education was related to poorer self-rated health among Blacks (OR = 1.86; 95% CI = 1.07, 3.24; P < .001). Conclusions. Symptomatic clinical factors played a proportionally larger role in self-assessment of health among Whites with diabetes and coronary artery disease than among Blacks with the same conditions. Racial differences in rates of type 2 diabetes mellitus and coronary artery disease, access to medical care, and clinical outcomes have been well documented. 1 Racial differences in perceived health status have also been reported in several patient populations. 1 – 4 Understanding how the relationship between objective clinical factors and perceived health status is affected by race may add to the ongoing discussion of the significance of race/ethnicity and its effect on existing disparities in cardiovascular outcomes that persist in the United States. Detrimental racial/ethnic effects are reflected in long-standing health disparities and the underrepresentation of racial/ethnic minority groups in clinical research. 5 Wyatt et al. theorized that racism affects cardiovascular risk factors on 3 levels: (1) institutionalized racism can affect socioeconomic status, (2) perceived racism acts as a psychophysiological stressor, and (3) internalized racism can give rise to risky health behaviors. Furthermore, the patient–provider relationship helps to mediate these pathways through (1) patterned disparities in treatments and interventions, (2) practitioner perceptual bias or stereotyping of patients, and (3) patient perceptions of bias in treatment. 6 , 7 Gill and Feinstein conducted a critical appraisal of quality of life (QOL) measures used in the medical literature. 8 The authors concluded that QOL was an individual perception that signified the way that individual patients felt about their health status and nonmedical aspects of their lives. The authors reported that most measurements of QOL in the medical literature seemed to aim at the wrong target and that QOL could be properly assessed only by establishing the opinions of patients in place of, or as a supplement to, instruments developed by experts. This is the context in which culture may shape individual assessments of QOL and therefore reflect differences along racial lines. McGee et al. investigated the relationship between self-rated health status and mortality by pooling data from the National Health Interview Surveys for 1986 to 1994 on more than 700 000 participants, with almost 17 000 Asian/Pacific Islanders, more than 90 000 Blacks, and more than 50 000 Hispanics. The authors found strong associations between self-rated health status and both socioeconomic status and subsequent mortality. They noted that “a self-report of fair or poor health was associated with at least a twofold increased risk of mortality for all racial/ethnic groups.” 4 (p41) We aimed to determine the extent to which racial/ethnic identity was associated with self-rated health status after adjustment for demographic characteristics, exercise, neuropathy, insulin use, and clinical measures such as angina and congestive heart failure. We also sought to determine whether any association between clinical factors and perceived health status was consistent between groups of diabetes patients as defined by race. We hypothesized that after control for clinical measures, race would be a determinant of self-rated health and that the magnitude of the association between these clinical factors and self-rated health would differ between races.
