Reducing Racial Disparities in the Health Status of African American Diabetic Patients: Toward a More Ideal Health Care System - Kavon Kaboli

Kavon Kaboli

12/10/09

The last several decades have brought about perplexing disparities in health between black and white populations residing in the United States. Ongoing research in medicine and public health underscore these differences and show that the gap in life expectancy between these populations is only widening. According to the National Center for Health Statistics, in 1996 the overall death rate for African Americans was 1.6 times higher than it was for the white population. In fact, the overall death rate for blacks today is comparable to the rate for whites thirty years ago (1). Support for this elevated death rate is derived from statistics on the top ten leading causes of death in the United States. Today, blacks incur higher rates of mortality for eight of these top ten leading causes of death (see table 1 in Appendix A) (2). A multitude of factors, including education, lifestyle choices, access to and quality of medical care, and the availability of health insurance have been enumerated as possible causes for these observed health discrepancies (3). Currently, the overwhelming majority of interventions aimed at mitigating these disparities seek to do so by improving general health care quality using the Chronic Care Model. This seems prudent, as extensive research shows that the quality of care for African Americans is worse than that for whites (4). Nonetheless, a preponderance of these interventions are hampered by critical shortcomings.

Racial disparities in the quality of diabetes care are persistent across all sectors of the U.S. health care system. Black patients with diabetes mellitus (DM) are less likely than white patients to receive recommended processes of care, including hemoglobin A1c and lipid testing and are less likely to achieve treatment goals such as glycemic, cholesterol, and blood pressure control (5,6). African Americans also experience poorer long-term diabetes-related outcomes than whites, including diabetic retinopathy, lower extremity amputations, and chronic kidney disease (7). In an effort to reduce racial disparities in DM care quality, the Harvard Vanguard Medical Associates (HVMA) – an integrated multispecialty group practice consisting of 14 ambulatory health centers in eastern Massachusetts – implemented a quality improvement program founded on the tenets of the Chronic Care Model. The HVMA intervention deployed a fully functional electronic medical record system. The system supported computerized ordering of medications and laboratory tests, decision support/clinical practice guidelines for chronic disease care, and electronic generation of specialty referrals by primary care physicians (8). The system also facilitated the creation of disease registries to monitor and improve care. In 1999, HVMA began using its clinical information systems to organize centralized outreach programs for DM patients. An electronic registry of patients with DM and their associated quality measures was developed using automated data collected from the electronic medical record system. Patients overdue for specific screening services received personalized letters recommending the needed service. In addition, electronic reminders were created within the system to prompt clinicians to provide overdue DM care for patients during office visits.

At first glance HVMA’s use of the Chronic Care Model in reducing DM disparities may seem adequate. This study demonstrated a reduction in racial disparities in health and quality of care associated with overall quality of improvement (8) – consistent with other quality improvement initiatives (9). Despite this, there are several glaring issues with implementing Chronic Care Model interventions in such a way:

(i) This model is designed to improve the health and care of patients that are already well established within the health care system.

(ii) It assumes a general approach to quality improvement and in this regard is not as effective for reducing racial disparities in health and care quality as a culturally tailored approach.

(iii) And finally, attainment of quality improvement is heavily dependent on physician adherence to clinical practice guidelines – which may not necessarily occur.

The Problem with Improving Primary Care Quality?

The problem with using the Chronic Care Model to reduce racial disparities in DM health outcomes and quality of care is the fact that they are designed to improve care for patients who have an established medical home and a regular primary care provider. Thus they fail to reach the most at-risk and disadvantaged populations on the margins of the health care system who do not have access to primary care providers. Previous studies examining disparities in diabetes prevalence and outcomes have suggested that disparities in healthcare resource allocation (10), healthcare utilization (10), and quality of diabetes care (11) are all sources of racial disparities in diabetes. A primary reason for to these inequities is socioeconomic status (SES). This is supported by research showing that health status varies by socioeconomic status and that African Americans are more likely to have low SES compared with whites (12). Simply stated, because the majority of African Americans reside at lower SES levels, they incur differences in health status and health care access and quality. Knowing this, why would an intervention aimed at reducing racial disparities in diabetes patients’ health and treatment only focus on individuals who are already receiving treatment? The patients most at risk for poor health outcomes are those on the fringe of health care systems – those who disproportionately rely on urgent and emergent care facilities for routine care. To be more effective, the Chronic Care Model needs to be implemented so that it targets these populations directly.

Establishing diabetes walk-in clinics is a concept that should be incorporated into interventions aimed at reducing racial disparities in health. A diabetes walk-in clinic could provide chronic disease management to the socially disadvantaged – uninsured, low income individuals without access to primary care physicians – a large percentage of whom are African American. Such a clinic could provide optimization of medication management and emphasize diabetes self-management education that patients would otherwise not receive from urgent and emergent care facilities. Another study analyzing the success of implementing a similar intervention strategy found that 73% of patients returned for a follow-up visit and over 70% were prescribed aspirin, ACE inhibtor, and a statin (13). Follow-up visits showed a greater than 50 percentage-point improvement in patient knowledge of target A1c levels and an understanding that uncontrolled diabetes can be detrimental (13). Despite possible social constraints, increases in vegetable and fruit consumption were observed and blood sugar values were significantly improved (13). This intervention demonstrates the value of incorporating quality improvements outside of the primary care setting for reaching socially disadvantaged blacks more effectively.

General vs. Culturally Tailored Interventions: Toward Increasing Intervention Effectiveness

A second significant drawback to HVMA’s use of the Chronic Care Model is that it tries to decrease racial differences in health status and health care using general quality improvements. This form of intervention fails to consider social context and ignores the importance of patient-provider communication and cultural competence during the treatment process. Cultural and linguistic competence is defined as “the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter” (17). At the patient-provider level this comprises the ability of individuals to establish effective interpersonal and working relationships to overcome cultural differences. Increasing amounts of literature demonstrate the significance of these factors by correlating positive health outcomes in diabetes control with enhanced provider communication and cultural awareness (14). This is of particular importance when the goal of the intervention (such as this one) is to decrease racial inequalities – especially since blacks have been shown to experience less patient-centered care, and more physician verbal dominance in their clinical encounters (15, 16). Cultural competence works to develop patient-provider trust and increases patient acceptability and adherence to medical advice. Recognizing the importance of social and cultural influences on patients and considering how these factors interact is the first step toward designing an effective intervention.

The idea is simple. If the goal of the HVMA intervention is to decrease racial disparities in diabetes care, then why not tailor it to the social and cultural context in which blacks live? The first step toward doing this is to utilize the racial data collected in the HVMA intervention to educate physicians regarding the importance of patient race in their own local health care environment. This is critical as a previous survey shows that while one-third of primary care physicians acknowledged the existence of racial disparities in diabetes care on a national level, less than 5% of primary care physicians reported such disparities within their own panel of patients (19). Until physicians are aware of possible racial discrepancies within their own practice, there will be no impetus for them to address such problems.

Several studies have reported that African American patients perceive less respect and poorer communication in race-discordant relationships with physicians (21). This is a prime example of how cultural incompetence can create distrust in the patient-doctor relationship. To minimize these occurrences, communication skills training programs for physicians that emphasize patient-centeredness should be incorporated into chronic care guidelines. Several other studies that have helped improve the health of disadvantaged groups have also demonstrated the effectiveness of cultural tailoring. For example, one intervention used culturally and linguistically appropriate written and audiovisual educational materials and attained higher quit rates for African-American smokers (20). Interventions aimed at decreasing racial disparities in DM care should also consider adopting CLAS (culturally and linguistically appropriate health care services) national standards. This would help increase physician awareness of possible social barriers and ensure the use of recommended practices related to culturally and linguistically appropriate services (17).

Finally, assurance and measurement of the degree to which a Chronic Care intervention is culturally sensitive could be achieved by incorporating patient and community input at all stages of intervention design, implementation and evaluation.

Barriers to Guideline Adherence: Why Don’t Physicians Follow Clinical Practice Guidelines?

A final critique of the Chronic Care Model that must be addressed when implementing cultural competence education and chronic care clinical practice guidelines are barriers to behavior change. Interventions such as the one enacted by HVMA (as well as the intervention described in the previous section) are heavily dependent and focused on changing provider behavior. However very few of these interventions have used models that account for barriers to behavior change. For instance, HVMA’s quality improvement approach seeks to improve patient health and treatment quality by providing primary care physicians with treatment guidelines. What exactly are these guidelines? Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decision about appropriate health care for specific clinical circumstances” (22). Guidelines should improve care by decreasing inappropriate variation and expediting the application of new advances (22), but the discussion ends there. It is assumed that physicians will agree with and therefore follow these guidelines simply because they are documented to be effective for patients. However, as any behavioral psychologist will tell you, this is not necessarily the case. Despite extensive circulation, guidelines have had limited effects on changing physician behavior (23). One asthma study found that only 46% of physicians were aware of National Heart, Lung and Blood Institute asthma guidelines (24). This is just one example of how physician adherence to practice guidelines may be hindered by a variety of barriers.

Lack of awareness is one reason why many physicians fail to adhere to guidelines. Ever-expanding bodies of research make it difficult for physicians to be aware of applicable guidelines and apply them to practice. It could also boil down to a physician simply not agreeing with a specific guideline or the concept of guidelines in general. Additional sources of poor adherence to diabetes care guidelines stem from self-efficacy and outcome expectancy. According to social cognitive theory, self-efficacy is the belief that one can perform a behavior despite poor outcomes whereas outcome expectancy is the belief that a behavior will lead to a particular result (25). Low self-efficacy due to a lack of confidence in ability or poor preparation could lead to poor guideline adherence. Similarly, if a physician believes that a recommendation will not lead to an improved outcome or that the patient will not heed medical advice, the physician will again be less likely to adhere to guidelines. The readiness for change model developed by Prochaska and DiClemente can also provide explanations for a provider’s barriers to adherence (26). This model suggests that many physicians are stuck in the pre-contemplation stage and will not adopt guideline recommendations without some initial force.

Interventions could address low outcome expectancy barriers by including targeted educational materials and programs for diabetes self-management. Educating patients regarding the benefits of DM management while away from the health clinic will not only improve health outcomes, it will also reduce outcome expectancy barriers that keep physicians from adhering to clinical guidelines. Simple considerations can also be made to decrease physicians’ lack of awareness to diabetes care guidelines. Many physicians have reported guidelines to be repetitious, dense and lengthy (27). Several case studies suggest that changing the perspective of chronic care guidelines from “research literature” to a clinical decision orientation and placing them on the front of patient charts will increase adherence (28).

These are just a few of the barriers to change that keep physicians from adhering to chronic care guidelines. If the HVMA and other chronic care interventions want to effectively reduce racial disparities in the health of diabetic patients these barriers must be considered and overcome.

Conclusion

Racial disparities in the health status and health care of black and white diabetic patients in the United States have been well documented. While research has revealed potential targets for interventions, many studies have met with limited success. Certain components of interventions to reduce racial disparities are of particular importance. To this end, interventions based on the Chronic Care Model should carefully consider the economic and cultural context of target populations, inform primary care providers of appropriate cultural and linguistic services, and address potential barriers to provider behavior change. Ideally, health care “reflects the total societal effort, whether public or private, to provide, organize, and finance services that promote the health status of individuals and the community”(29). These are three simple steps we can take toward creating a more ideal health care system for all people.

REFERENCES

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APPENDIX A

TABLE 1. Mortality rates for blacks and black/white ratios (age-adjusted death rates per 100,000 for the leading causes of death in 1995)^*

			1950				1995
Causes of Death		Black Rate		B/W Ratio		Black Rate		B/W Ratio
All Causes		1236.7		1.55		765.7		1.58
Heart Disease		379.6		1.26		198.8		1.49
Cancer		129.1		1.04		171.6		1.35
Cerebrovascular Disease		150.9		1.81		45		1.82
Pulmonary Disease		-		-		17.6		0.83
Unintentional Injury		70.9		1.27		37.4		1.25
Flu and Pneumonia		57		2.49		17.8		1.44
Diabetes		17.2		1.24		28.5		2.44
HIV/AIDS		-		-		51.8		4.67
Suicide		4.2		0.36		6.9		0.58
Cirrhosis		7.2		0.84		9.9		1.34
Homicide		30.5		11.73		33.4		6.07

^*National Center for Health Statistics 1995