race, disparities, diabetes, Plan-Do-Study-Act
Background: Racial disparities in diabetes care have been documented. Disparities also have been shown to affect service quality and outcome of diabetic care. Analysis of our internal medicine residency clinic diabetic care management performance across REAL-G (race, ethnicity, age, preferred language and/or gender) showed race-based disparity on two outcome measures: 1) measurement of glycohemoglobin (A1C) at least twice a year; and 2) target blood pressure of < 140/90.
Purpose: Develop interventions to decrease racial disparities in diabetes care among patients managed by an internal medicine residency clinic, as part of the Alliance of Independent Academic Medical Center’s National Initiative V project.
Methods: Interventions were developed following analysis of clinic performance data by REAL-G categories, workflow analysis and multidisciplinary clinic team meetings. A point-of-care A1C machine was procured and workflow developed using the Plan-Do-Study-Act cycle. Staff training was conducted. A rolling 12 months data set was obtained from electronic health records. Baseline data range was December 2014 to November 2015, while endline data were from January 2016 to December 2016. The interventions were launched in July 2016. Percentage difference between baseline and endline outcome indicators was calculated and Z-score test assessed. Statistical significance was set at P < 0.05.
Results: At baseline, 62.9% (401 of 638) of patients who self-identified as African American/black (AA) had A1C measured at least twice a year compared to 74.3% (107 of 144) of patients who self-identified as white/Caucasian (WC), a percentage difference of 11.4% (P = 0.01). For goal blood pressure in diabetics, 71.0% (453 of 638) of AA met the target as compared to 80.6% (116 of 144) of WC, a percentage difference of 9.6% (P = 0.003). Following the intervention, a higher percentage of AA patients (71.4% [381 of 534]) had at least two A1C measured during project period. The outcome also showed improvement for WC (79.8% [95 of 119]). The percentage difference between races narrowed to 8.5% (P = 0.06). For goal blood pressure, 75.1% of AA achieved the target compared to 81.5% of WC, with percentage difference narrowing to 6.4% (P = 0.14).
Conclusion: Racial disparities in diabetes were confirmed, even for a clinic setting in which black patients are predominant. Racial disparity can be improved by implementing interventions that improve service for all patients.
Irena A, Patel K, Thompson D, Schleis G, Gesese A, Battiola R. Improved service efficiency improves racial disparity in diabetic care. J Patient Cent Res Rev. 2017;4:257.