1. The Effect of Quality Improvement on Racial Disparities in Diabetes Care Thomas D. Sequist, MD MPH Alyce S. Adams, PhD Fang Zhang, MS Dennis Ross-Degnan, ScD John Z. Ayanian, MD MPP 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

2. Background Gaps between evidence and quality exist for diabetes care Gaps between evidence and quality exist for diabetes care Racial disparities in quality well documented Racial disparities in quality well documented Generic quality improvement is a potential solution to reduce disparities Generic quality improvement is a potential solution to reduce disparities

3. Study Goals Assess baseline racial differences in diabetes care within a large multispecialty group practice Assess baseline racial differences in diabetes care within a large multispecialty group practice Analyze impact of generic quality improvement efforts on existing racial disparities Analyze impact of generic quality improvement efforts on existing racial disparities

4. Methods – Study Site Harvard Vanguard Medical Associates Harvard Vanguard Medical Associates Integrated multispecialty group practice Integrated multispecialty group practice –14 health centers in Boston area –250,000 adult patients Generic QI efforts during 1997 to 2001 Generic QI efforts during 1997 to 2001 –Implemented electronic health record –Computerized reminders to physicians –Disease registries/ centralized outreach to patients

5. Methods - Study Population Adult patients  18 years with 24 months continuous enrollment in Harvard Pilgrim Health Care Adult patients  18 years with 24 months continuous enrollment in Harvard Pilgrim Health Care Diabetes diagnosis Diabetes diagnosis –  1 inpatient diagnosis diabetes mellitus, or –  2 outpatient diagnoses diabetes mellitus, or –Dispensing of diabetes drug (insulin, oral agent) Rolling annual cohort Rolling annual cohort –1997 to 2001 –Diagnosis of diabetes for entire calendar year

6. Methods - Quality Measures Collected from electronic medical record Collected from electronic medical record Cholesterol management Cholesterol management –Annual lipid testing –LDL control (< 130 mg/dL) –Statin dispensing (pharmacy claims) Glycemia management Glycemia management –Annual HbA1c testing –HbA1c control (< 7.0%) Annual retinopathy screening Annual retinopathy screening

7. Methods - Analysis Baseline (1997) racial differences in care Baseline (1997) racial differences in care –Multivariate logistic regression –GEE to account for clustering of patients –Adjusted for age, gender Longitudinal changes in disparities Longitudinal changes in disparities –Similar to baseline models –Data included for 1997 to 2001 –Race*year interaction term

8. Patient Characteristics White (n = 5,101) Black (n = 1,987) p value Mean age, years Male, % Long Term Enrollment*, % 60.2517453.84173<0.001<0.0010.44 * Enrolled for at least 3 out of the 5 study years

9. Annual LDL Cholesterol Monitoring Adjusted p<0.001 (race*year interaction)

10. LDL Cholesterol Control Adjusted p<0.001 (race*year interaction)

11. Statin Use Adjusted p=0.23 (race*year interaction)

12. Annual HbA1c Monitoring Adjusted p=0.11 (race*year interaction)

13. HbA1c Control Adjusted p=0.47 (race*year interaction)

14. Dilated Eye Exams Adjusted p=0.77 (race*year interaction)

15. Limitations Single multispecialty group practice with advanced EMR Single multispecialty group practice with advanced EMR Unmeasured confounding Unmeasured confounding No measures of patient experience with care No measures of patient experience with care

16. Discussion Baseline disparities in diabetes care Baseline disparities in diabetes care –Substantial disparity in low performing measures –No disparity in high performing measures Cholesterol management quality improvement Cholesterol management quality improvement –Reduction in process measure disparity –Less marked reduction in outcome measure disparity –Disparity in statin use persisted Glycemia management Glycemia management –No disparity in process measure –No quality improvement in outcome measure –Disparity in outcome measure persisted

17. Implications Health care organizations can and should measure disparities in care Health care organizations can and should measure disparities in care Generic quality improvement may represent an effective tool to diminish disparities Generic quality improvement may represent an effective tool to diminish disparitiesBut…. Important to monitor outcomes measures and patterns of treatment Important to monitor outcomes measures and patterns of treatment Persistent disparities may require specific focus on minority health Persistent disparities may require specific focus on minority health

19. Electronic Reminders

20. Centralized Patient Mailings

21. Changes in Cholesterol Management by Gender

22. Annual LDL Testing by Center* 19972001 HVMA Center WhiteBlackWhiteBlack  in Disparity 123453639425038202830383063686868646063656360136964 * Among centers with at least 50 black patients

23. LDL Control by Center* 19972001 HVMA Center WhiteBlackWhiteBlack  in Disparity 12345151319191461296104152504644424341334110(8)103 * Among centers with at least 50 black patients