Comparison of Laboratory Test Frequency and Test Results Between African-Americans and Caucasians With Diabetes: Opportunity for Improvement: Findings from a large urban health maintenance organization

Wisdom, Kimberlydawn; Fryzek, Jon P.; Havstad, Suzanne; Anderson, Robert M.; Dreiling, Michael C.; Tilley, Barbara C.

doi:10.2337/diacare.20.6.971

Cited by 73 publications

(43 citation statements)

References 19 publications

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“…In particular, the combined race and sex effect found in our study may reflect differences in the availability of social support and its relationship to selfmanagement (42,43). Other researchers have found evidence of a combined race and sex effect in quality and outcomes (7,10,28,44,45).…”

Section: Race and Long-term Diabetes Managementmentioning

confidence: 95%

“…A high prevalence of poor glycemic control and outcomes among black diabetic patients (7)(8)(9)(10)(11)(12)(13)(14) may be attributable in part to inequalities in insurance coverage (15,16) and lower quality of care within clinics serving predominantly black patients (17)(18)(19). Yet, racial differences in care have also been demonstrated within coordinated care systems, such as the Veterans Administration health system (20 -23).…”

mentioning

confidence: 99%

“…Evidence of racial differences in o u t c o m e s w i t h i n t h e s e s y s t e m s (10,28,32) suggests that the primary causes of racial disparities may transcend the health care setting (e.g., genetics, culture, home environment, and/or psychosocial barriers to medication and lifestyle adherence). Few studies have examined racial differences in diabetes outcomes among HMO patients using a longitudinal design (30,32).…”

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confidence: 99%

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Race Differences in Long-Term Diabetes Management in an HMO

et al. 2005

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OBJECTIVE -We examined race differences in diabetes outcomes over 4 -8 years in a single HMO.RESEARCH DESIGN AND METHODS -We identified black and white adult diabetic patients who were continuously enrolled (1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001) and in whom diabetes was 1) diagnosed before 1994 (n ϭ 1,686) or 2) newly diagnosed in 1994 -1997 (n ϭ 1,280). We used hierarchical models to estimate the effect of race on average annual HbA 1c (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race.RESULTS -At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI Ϫ0.12 to 0.34) in black than in white men but was 0.30 higher (0.14 -0.46; P ϭ 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17-0.80; P ϭ 0.007) and was 0.05 among women (Ϫ0.20 to -0.31), which was positive but not significant.CONCLUSIONS -Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management. Diabetes Care 28:2844 -2849, 2005D iabetes is a focal point in efforts to reduce health disparities in the U.S.(1-5), where an estimated 8.5% of racial differences in mortality are attributable to diabetes alone (6). A high prevalence of poor glycemic control and outcomes among black diabetic patients (7-14) may be attributable in part to inequalities in insurance coverage (15,16) and lower quality of care within clinics serving predominantly black patients (17)(18)(19)). Yet, racial differences in care have also been demonstrated within coordinated care systems, such as the Veterans Administration health system (20 -23).HMOs provide a system-level focus on standardization of care that may limit decision making based on nonclinical patient characteristics when these decisions conflict with quality-of-care guidelines (24 -31). Evidence of racial differences in o u t c o m e s w i t h i n t h e s e s y s t e m s (10,28,32) suggests that the primary causes of racial disparities may transcend the health care setting (e.g., genetics, culture, home environment, and/or psychosocial barriers to medication and lifestyle adherence). Few studies have examined racial differences in diabetes outcomes among HMO patients using a longitudinal design (30,32).In a setting in which patients have equal access to care, we examine...

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Section: Race and Long-term Diabetes Managementmentioning

confidence: 95%

mentioning

confidence: 99%

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confidence: 99%

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Race Differences in Long-Term Diabetes Management in an HMO

et al. 2005

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“…Many studies (14,15,50 -55) have investigated quality of care and intermediate outcomes of care. Unfortunately, with the exception of four studies (14, 53,55,56), most research has treated the measurements separately and not analyzed the associations. The first study (53) examined several factors that may explain why black patients, compared with whites, have worse intermediate outcomes (glycemic control).…”

Section: Ethnic Differences In Quality Of Carementioning

confidence: 99%

“…However, in this study, no ethnic differences in glycemic control were found. In the second study (55), process of care (frequencies of tests: e.g., A1C) of African Americans and Caucasians were compared. The finding that African Americans were in poorer metabolic control than Caucasians led to the analysis of the relationship of glycemic control to determine test frequency per group.…”

Section: Ethnic Differences In Quality Of Carementioning

confidence: 99%

Ethnic Differences in Mortality, End-Stage Complications, and Quality of Care Among Diabetic Patients

et al. 2005

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OBJECTIVE -To determine the influence of ethnic differences in diabetes care on inequalities in mortality and prevalence of end-stage complications among diabetic patients. The following questions were examined: 1) Are there ethnic differences among diabetic patients in mortality and end-stage complications and 2) are there ethnic differences among diabetic patients in quality of care?RESEARCH DESIGN AND METHODS -A review of the literature on ethnic differences in the prevalence of complications and mortality among diabetic patients and in the quality of diabetes care was performed by systematically searching articles on Medline published from 1987 through October 2004.RESULTS -A total of 51 studies were included, mainly conducted in the U.S. and the U.K. In general, after adjusting for confounders, diabetic patients from ethnic minorities had higher mortality rates and higher risk of diabetes complications. After additional adjustment for risk factors such as smoking, socioeconomic status, income, years of education, and BMI, in most instances ethnic differences disappear. Nevertheless, blacks and Hispanics in the U.S. and Asians in the U.K. have an increased risk of end-stage renal disease, and blacks and Hispanics in the U.S. have an increased risk of retinopathy. Intermediate outcomes of care were worse in blacks, and they were inclined to be worse in Hispanics. Likewise, ethnic differences in quality of care in the U.S. exist: process of care was worse in blacks.CONCLUSIONS -Given the fact that there are ethnic differences in diabetes care and that ethnic differences in some diabetes complications persist after adjustment for risk factors other than diabetes care, it seems the case that ethnic differences in diabetes care contribute to the more adverse disease outcomes of diabetic patients from some ethnic minority groups. Although no generalizations can be made for all ethnic groups in all regions for all kinds of complications, the results do implicate the importance of quality of care in striving for equal health outcomes among ethnic minorities. Diabetes Care 28:2280 -2288, 2005D iabetes is one of the most common chronic diseases in Europe and the U.S. (1-3). Diabetes is divided into etiologic subclasses, of which type 1 and type 2 are the most prevalent (4). The prevalence of type 1 and, in particular, type 2 diabetes is rising in all European countries (2). Type 2 diabetes is the major contributor to the epidemic rise in diabetes because this type accounts for Ͼ90% of diabetes. In the U.S., the overall prevalence of diabetes increased from 4.9% in 1990 to 6.5% in 1998 (5). There is a parallel rise in the prevalence of complications related to diabetes.The prevalence of diabetes varies, among other factors, by ethnicity. Several studies (3,6,7) on ethnic differences in diabetes have reported higher prevalence and incidence rates among ethnic minorities. Furthermore, end-stage complications of diabetes have been reported to be more common among ethnic minorities (8 -10), who also experience higher morta...

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Comparing Generalist and Specialty Care

Donohoe

1998

Arch Intern Med

166

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Policymakers, managed care organizations, medical educators, and the general public are showing an increasing interest in the amount and quality of care provided by generalists and subspecialists. This article reviews studies comparing the knowledge base of and quality of care provided by these 2 groups of physicians. English-language articles were identified through MEDLINE (1966-present) using the following keywords: generalist, generalism, (sub)specialist, (sub)specialty, (sub)specialization, consultation, referral, and quality of care, and through the bibliographies of these citations. All studies were evaluated. With respect to quality of care, only American studies were chosen. Data quality was assessed by me. Evidence is strongest that the knowledge base and quality of care provided by specialists exceeds those of generalists for certain conditions such as myocardial infarction, depression, and acquired immunodeficiency syndrome. Differences in many other areas are multifactorial, and often a function of study design or patient selection. The differences, however, are not as striking or important to the health of the public at large as those deficiencies in disease management, preventive care, and health maintenance that are common to all physicians. Furthermore, overuse of diagnostic and therapeutic modalities by certain specialists leads to increased costs with either no benefit or added risks to patients. The quality and coordination of care provided by generalists and specialists may be improved through changes in education and training, via quality improvement methods of providing patient care, and by increasing visit length and optimizing use of referrals and strategies for generalist-specialist comanagement. Further study of these areas is warranted and should concentrate on outcomes.Arch Intern Med. 1998;158:1596-1608 This article evaluates the amount and quality of care provided by generalists and specialists, a subject of increasing interest to medical educators, managed care organizations, and the general public. Weaknesses in the knowledge base of practicing physicians are reviewed, and investigations attempting to compare generalist and specialty care for common conditions are described. While some of the differences in quality of care may be due to generalists' knowledge deficits, many are secondary to system factors and most are remediable. Furthermore, disparities between generalist and specialty care likely have less impact on the population's health than the deficiencies all physicians share. After discussing the nature of these deficiencies, I explain how they might be corrected and how generalists and specialists can work together, building on their respective strengths, to improve the quality of health care in this country.

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Comparison of Laboratory Test Frequency and Test Results Between African-Americans and Caucasians With Diabetes: Opportunity for Improvement: Findings from a large urban health maintenance organization

Abstract: The opportunity exists to improve the process of care for both African-Americans and Caucasians with diabetes in an HMO setting. The need to improve glycosylated hemoglobin results and subsequently limit complications is especially pressing among the African-American population.

Cited by 73 publications

References 19 publications

Race Differences in Long-Term Diabetes Management in an HMO

Race Differences in Long-Term Diabetes Management in an HMO

Ethnic Differences in Mortality, End-Stage Complications, and Quality of Care Among Diabetic Patients

Comparing Generalist and Specialty Care

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