The Effect of Quality Improvement on
Racial Disparities in Diabetes Care
Thomas D. Sequist, MD MPH
Alyce S. Adams, PhD
Fang Zhang, MS
Dennis RossRoss-Degnan, ScD
John Z. Ayanian, MD MPP
Background
„
Gaps between evidence and quality exist
for diabetes care
„
Racial disparities in quality well
documented
„
Generic quality improvement is a potential
solution to reduce disparities
Division of General Medicine, Brigham and Women’s Hospital
Department of Health Care Policy, Harvard Medical School
Department of Ambulatory Care and Prevention, Harvard Medical School
School
Study Goals
„
„
Assess baseline racial differences in
diabetes care within a large
multispecialty group practice
Analyze impact of generic quality
improvement efforts on existing racial
disparities
Methods - Study Population
„
„
Adult patients ≥ 18 years with 24 months
continuous enrollment in Harvard Pilgrim
Health Care
„
Harvard Vanguard Medical Associates
„
Integrated multispecialty group practice
– 14 health centers in Boston area
– 250,000 adult patients
„
Implemented electronic health record
Computerized reminders to physicians
Disease registries/ centralized outreach to patients
Methods - Quality Measures
„
Collected from electronic medical record
„
Cholesterol management
– Annual lipid testing
– LDL control (< 130 mg/dL
mg/dL))
– Statin dispensing (pharmacy claims)
„
Glycemia management
– Annual HbA1c testing
– HbA1c control (< 7.0%)
Rolling annual cohort
– 1997 to 2001
– Diagnosis of diabetes for entire calendar year
Generic QI efforts during 1997 to 2001
–
–
–
Diabetes diagnosis
– ≥ 1 inpatient diagnosis diabetes mellitus, or
– ≥ 2 outpatient diagnoses diabetes mellitus, or
– Dispensing of diabetes drug (insulin, oral agent)
„
Methods – Study Site
„
Annual retinopathy screening
1
Methods - Analysis
Patient Characteristics
Baseline (1997) racial differences in care
„
– Multivariate logistic regression
– GEE to account for clustering of patients
– Adjusted for age, gender
Black
(n = 1,987)
p
value
60.2
53.8
<0.001
Male, %
51
41
<0.001
Long Term Enrollment*, %
74
73
0.44
Mean age, years
Longitudinal changes in disparities
„
White
(n = 5,101)
– Similar to baseline models
– Data included for 1997 to 2001
– Race*year interaction term
* Enrolled for at least 3 out of the 5 study years
100
LDL Cholesterol Control
100
Adjusted p<0.001 (race*year interaction)
90
80
63
70
60
50
40
43
30
20
10
46
51
65
62
53
35
White
Black
40
29
% Acheiving LDL < 130 mg/dL
% Receiving Annual LDL Testing
Annual LDL Cholesterol Monitoring
Adjusted p<0.001 (race*year interaction)
90
80
70
60
50
40
29
30
20
10
1997
1998
1999
2000
19
70
60
50
40
22
26
20
15
18
1997
1998
30
23
35
39
27
30
2000
2001
White
Black
% Receiving Annual HbA1c
% Prescribed Statin
1999
2000
2001
100
Adjusted p=0.23 (race*year interaction)
80
10
1998
Annual HbA1c Monitoring
100
30
13
1997
2001
Statin Use
90
30
9
0
0
39
21
18
White
Black
45
40
90
80
79
80
77
76
77
70
76
75
74
75
76
60
White
Black
50
40
30
20
10
Adjusted p=0.11 (race*year interaction)
0
0
1999
1997
1998
1999
2000
2001
2
HbA1c Control
Dilated Eye Exams
100
% Acheiving HbA1c < 7.0%
90
80
% Receiving Annual Eye Exam
100
Adjusted p=0.47 (race*year interaction)
70
60
50
40
34
35
37
24
26
28
34
36
27
26
White
Black
30
20
10
90
80
75
71
68
69
71
66
63
65
66
70
60
71
50
40
White
Black
30
20
10
Adjusted p=0.77 (race*year interaction)
0
0
1997
1998
1999
2000
1997
2001
„
Single multispecialty group practice with
advanced EMR
„
Unmeasured confounding
„
No measures of patient experience with care
1999
2000
2001
Discussion
Limitations
„
1998
Baseline disparities in diabetes care
– Substantial disparity in low performing measures
– No disparity in high performing measures
„
Cholesterol management quality improvement
– Reduction in process measure disparity
– Less marked reduction in outcome measure disparity
– Disparity in statin use persisted
„
Glycemia management
–
–
–
No disparity in process measure
No quality improvement in outcome measure
Disparity in outcome measure persisted
Implications
„
Health care organizations can and should measure
disparities in care
„
Generic quality improvement may represent an
effective tool to diminish disparities
But….
„ Important to monitor outcomes measures and
patterns of treatment
„
Persistent disparities may require specific focus on
minority health
3
Centralized Patient Mailings
Electronic Reminders
Changes in Cholesterol Management by Gender
Annual LDL Testing by Center*
1997
2001
White
Black
White
Black
Δ in Disparity
1
36
20
63
60
13
2
39
28
68
63
6
3
42
30
68
65
9
4
50
38
68
63
6
5
38
30
64
60
4
HVMA
Center
* Among centers with at least 50 black patients
LDL Control by Center*
1997
HVMA
Center
White
2001
Black
White
Black
Δ in Disparity
1
15
6
41
42
10
2
13
12
52
43
(8)
3
19
9
50
41
1
4
19
6
46
33
0
5
14
10
44
41
3
* Among centers with at least 50 black patients
4