Racial disparities exist among diabetes patients treated by the same physician

Harvard Medical School. Department of Health Care Policy. 180 Longwood Avenue, Boston, MA 02115-5899, E-mail Thomas D. Sequist, MD, MPH. Phone: 1 617-432-3447, Fax: 1 617-432-3696. Thomas D. Sequist, MD, MPH, is an assistant professor of medicine and of health care policy at Harvard Medical School and Brigham and Women’s Hospital. He currently practices general internal medicine at Harvard Vanguard Medical Associates. Thomas D. Sequist, MD, MPH

Black patients with diabetes are less likely than white patients to achieve long-term control of their blood glucose, blood cholesterol and blood pressure levels, even when they are treated by the same physician, according to a report in the June 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Racial disparities in the quality of diabetes care have been previously documented, according to background information in the article. Black patients with diabetes are less likely to receive recommended components of care, including hemoglobin A1C testing (HbA1C, a measure of blood glucose control over time) and lipid testing, and to achieve treatment goals, such as controlled blood pressure, cholesterol and blood glucose levels. In addition, black patients are more likely than white patients to develop diabetes-related eye and kidney disease and to have amputations of their lower extremities. "Identifying the underlying reasons and potential solutions for these differences in quality of care and outcomes is a high priority," the authors write. Thomas D. Sequist, M.D., M.P.H., of Harvard Vanguard Medical Associates, Boston, and colleagues analyzed electronic medical records from 4,556 white patients and 2,258 black patients with diabetes treated by 90 primary care physicians in eastern Massachusetts.

Each physician treated at least five black patients and five white patients; all patients were age 18 or older and had visited the physician within the last two years.

Black patients and white patients received tests of low-density lipoprotein (LDL or "bad") cholesterol and HbA1C at similar rates. However, white patients were more likely than black patients to reach commonly accepted benchmarks for controlled levels of HbA1C (47 percent vs. 39 percent), LDL cholesterol (57 percent vs. 45 percent) and blood pressure (30 percent vs. 24 percent).

"Patient sociodemographic factors explained 13 percent to 38 percent of the racial differences in these measures, whereas within-physician effects accounted for 66 percent to 75 percent of the differences," the authors write. "Thus, racial differences in outcomes were not related to black patients differentially receiving care from physicians who provide a lower quality of care, but rather that black patients experienced less ideal or even adequate outcomes than white patients within the same physician panel."

The variation in diabetes care was not related to overall performance or the volume of black patients treated by individual physicians, the authors note. "Our data suggest that the problem of racial disparities is not characterized by only a few physicians providing markedly unequal care, but that such differences in care are spread across the entire system, requiring the implementation of system-wide solutions," they write. "Efforts to eliminate these disparities, including race-stratified performance reports and programs to enhance care for minority patients, should be addressed to all physicians."

Editor's Note: This study was funded by the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change National Program. Dr. Sequist serves as a consultant on the Aetna External Advisory Committee for Racial and Ethnic Equality. Co-author Dr. Ayanian serves as a consultant to RTI International and DxCG Inc. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Results Offer Opportunity for Physician Leadership

"The findings presented by Sequist et al build nicely on prior work and are important and provocative," writes Carolyn Clancy, M.D., of the Agency for Healthcare Research and Quality, Rockville, Md., in an accompanying editorial.

"They now have an opportunity to examine physicians' reactions and how care changes when physicians are provided feedback on their performance," Dr. Clancy writes. "Eliminating disparities in health care will require that all patients have access to care, as well as physician leadership to assure that the care provided is evidence-based, patient-centered, effective, consistent and equitable."

(Arch Intern Med. 2008;168[11]:1145-1151. Available pre-embargo to the media at www.jamamedia.org.) ###

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