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No Matter the Doctor, Black Diabetics Fare Worse Than White Counterparts
Date:6/10/2008

Study found doctors with patients of both races still showed disparities in outcomes

TUESDAY, June 10 (HealthDay News) -- New research shows that black patients with diabetes tend to fare worse than white patients do, even if they see the same doctor.

In other words, the gap can't be explained by saying particular doctors tend to give substandard care. Racial disparities in diabetes care appear to be more the result of systemic issues, according to a study in the June 9 issue of the Archives of Internal Medicine.

"It wasn't so much that black patients weren't receiving care from lower-quality providers," said study author Dr. Thomas D. Sequist, a primary-care physician at Harvard Vanguard Medical Associates. "Amongst all providers, black patients received lower quality care, even if white patients went to the same doctors."

"There have been some other studies that have shown just as much as who you are predicts what kind of care you get [race, income, gender], where you get care oftentimes is just as important or more important," Sequist continued.

Sequist and his co-authors wanted to see how far down the health-care system chain disparities went. Did it extend only to the hospital level, with some hospitals caring mostly for black patients providing lower quality care? Did the breakdown occur with individual physicians? Or was the problem even broader in scope?

This study looked at 90 primary-care physicians, each caring for at least five black and at least five white adult patients with type 2 diabetes. The physicians and patients were located at 13 different outpatient sites. In all, the study involved 4,556 white adults and 2,258 black adults being cared for at Harvard Vanguard Medical Associates.

White patients were more likely to achieve control of several key indicators of diabetes control: 47 percent of whites had control of hemoglobin A1c levels (an over-time measure of blood sugar levels) versus only 39 percent of blacks; 57 percent of whites had LDL ("bad") cholesterol levels in check, compared with 45 percent of blacks; and 30 percent of whites had their blood pressure in normal zones compared with 24 percent of blacks.

Socio-demographic factors, such as patient income and insurance explained some of the difference, in the order of about 20 percent to 30 percent, Sequist said. In other words, certain types of patients tended to cluster within certain providers.

Other diseases and conditions such as obesity or heart disease explained virtually none of the difference.

"Then you're still left with this big chunk of difference, and the question is why," Sequist said.

As it turned out, medication prescription rates tended to be lower among blacks, which might account for some of the discrepancy.

But the study was unable to explain why that might be. "We get all our data from charts and electronic medical records, so we don't have details about what discussions might have happened between physicians and patients that might have led to that lower rate," Sequist said. "Was counseling less effective among African-Americans? Were there differences in their ability to afford these medications and, if so, did the case provider decide not to order them? We don't have those types of differences."

"It's difficult to elucidate what exactly is the cause," pointed out Dr. Joel Zonszein, director of the clinical diabetes center at Montefiore Medical Center and Albert Einstein College of Medicine in New York City. "It's important to be aware of these disparities, and the issue will be to find out how to reduce them."

Sequist was also the lead author on a May 2008 study in the Journal of General Internal Medicine that found that 88 percent of primary-care clinicians agree that racial disparities in health care are a problem, but only 40 percent felt the disparities existed in their own patient populations.

That means the solution needs to begin at home. Sequist is conducting a randomized trial to see if such measures as cultural-competence training, community tours so physicians will know more about disease management outside of the 20-minute office visit (for instance, exercise and diet options in the neighborhood), and performance feedbacks.

"From our organization's perspective, the solution meant that we had to implement programs that affected all of our doctors, not a program that identified 10 to 20 lower-performing physicians and do some sort of boot-camp, quality-improvement strategy," Sequist said. "Instead, we decided to try and increase awareness amongst all physicians, and try to provide tools to deliver better diabetes care to minority patients amongst all our physicians."

More information

The Agency for Healthcare Research and Quality has more on racial disparities in diabetes.



SOURCES: Thomas Sequist, M.D., general internist, Harvard Vanguard Medical Associates, and assistant professor, Harvard Medical School and Brigham and Women's Hospital, Boston; Joel Zonszein, M.D., director, clinical diabetes center, Montefiore Medical Center and Albert Einstein College of Medicine, New York City; June 9, 2008, Archives of Internal Medicine


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