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Reducing Racial/Ethnic Disparities in Diabetes: The Coached Care (R2D2C2) Project

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ABSTRACT

BACKGROUND

Despite numerous efforts to change healthcare delivery, the profile of disparities in diabetes care and outcomes has not changed substantially over the past decade.

OBJECTIVE

To understand potential contributors to disparities in diabetes care and glycemic control.

DESIGN

Cross sectional analysis.

SSETTING

Seven outpatient clinics affiliated with an academic medical center.

PATIENTS

Adult patients with type 2 diabetes who were Mexican American, Vietnamese American or non-Hispanic white (n = 1,484).

MEASUREMENTS

Glycemic control was measured as hemoglobin A1c (HbA1c) level. Patient, provider and system characteristics included demographic characteristics; access to care; quality of process of care including clinical inertia; quality of interpersonal care; illness burden; mastery (diabetes management confidence, passivity); and adherence to treatment.

RESULTS

Unadjusted HbA1c values were significantly higher for Mexican American patients (n = 782) (mean = 8.3 % [SD:2.1]) compared with non-Hispanic whites (n = 389) (mean = 7.1 % [SD:1.4]). There were no significant differences in HbA1c values between Vietnamese American and non-Hispanic white patients. There were no statistically significant group differences in glycemic control after adjustment for multiple measures of access, and quality of process and interpersonal care. Disease management mastery and adherence to treatment were related to glycemic control for all patients, independent of race/ethnicity.

LIMITATIONS

Generalizability to other minorities or to patients with poorer access to care may be limited.

CONCLUSIONS

The complex interplay among patient, physician and system characteristics contributed to disparities in HbA1c between Mexican American and non-Hispanic white patients. In contrast, Vietnamese American patients achieved HbA1c levels comparable to non-Hispanic whites and adjustment for numerous characteristics failed to identify confounders that could have masked disparities in this subgroup. Disease management mastery appeared to be an important contributor to glycemic control for all patient subgroups.

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REFERENCES

  1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–2645.

    Article  PubMed  Google Scholar 

  2. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335–342.

    Article  PubMed  CAS  Google Scholar 

  3. Greenfield S, Kaplan SH, Kahn R, Ninomiya J, Griffith JL. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med. 2002;136(2):111–121.

    Article  PubMed  Google Scholar 

  4. Keating NL, Landrum MB, Landon BE, Ayanian JZ, Borbas C, Wolf R, et al. The influence of physicians’ practice management strategies and financial arrangements on quality of care among patients with diabetes. Med Care. 2004;42(9):829–839.

    Article  PubMed  Google Scholar 

  5. Landon BE, Wilson IB, McInnes K, Landrum MB, Hirschhorn L, Marsden PV, et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med. 2004;140(11):887–896.

    Article  PubMed  Google Scholar 

  6. Shojania K, Ranji S, McDonald K, Grimshaw J, Sundaram V, Rushakoff R, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006;296(4):427–438.

    Article  PubMed  CAS  Google Scholar 

  7. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manage Healthc. 2005;11(8):478–488.

    Google Scholar 

  8. Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. Rockville: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2012.

    Google Scholar 

  9. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. . Centers for Disease Control and Prevention. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.

  10. Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diabetes Care. 2001;24(3):454–459.

    Article  PubMed  CAS  Google Scholar 

  11. Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 Suppl):101S–156S.

    Article  PubMed  Google Scholar 

  12. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in medicare managed care. N Engl J Med. 2005;353(7):692–700.

    Article  PubMed  CAS  Google Scholar 

  13. National Committee for Quality Assurance. The State of Health Care Quality 2009: Value, Variation and Vulnerable Populations. Washington, D.C.: National Committee for Quality Assurance; 2009.

    Google Scholar 

  14. Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med. 1998;129(5):406–411.

    Article  PubMed  CAS  Google Scholar 

  15. Brown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF, et al. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev. 2004;26(1):63–77.

    Article  PubMed  Google Scholar 

  16. LaVeist T, Pollack K, Thorpe R, Fesahazion R, Gaskin D. Place, not race: disparities dissipate in Southwest Baltimore when blacks and whites live under similar conditions. Health Aff. 2011;30(10):1880–1887.

    Article  Google Scholar 

  17. Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000;9(10):1156–1163.

    Article  PubMed  CAS  Google Scholar 

  18. Levetan CS, Passaro MD, Jablonski KA, Ratner RE. Effect of physician specialty on outcomes in diabetic ketoacidosis. Diabetes Care. 1999;22(11):1790–1795.

    Article  PubMed  CAS  Google Scholar 

  19. Ngo-Metzger Q, Sorkin DH, Phillips RS, Greenfield S, Massagli MP, Clarridge B, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22:324–330.

    Article  PubMed  Google Scholar 

  20. Kerr EA, Gerzoff RB, Krein SL, Selby JV, Piette JD, Curb JD, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4):272–281.

    Article  PubMed  Google Scholar 

  21. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Relationship between quality of care and racial disparities in Medicare health plans. JAMA. 2006;296(16):1998–2004.

    Article  PubMed  CAS  Google Scholar 

  22. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient–physician communication during medical visits. Am J Public Health. 2004;94(12):2084–2090.

    Article  PubMed  Google Scholar 

  23. Saha S, Arbelaez JJ, Cooper LA. Patient–physician relationships and racial disparities in the quality of health care. Am J Public Health. 2003;93(10):1713–1719.

    Article  PubMed  Google Scholar 

  24. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patient–physician relationship. JAMA. 1999;282(6):583–589.

    Article  PubMed  CAS  Google Scholar 

  25. Vargas Bustamante A, Chen J. Physicians cite hurdles ranging from lack of coverage to poor communication in providing high-quality care to Latinos. Health Aff. 2011;30(10):1921–1929.

    Article  Google Scholar 

  26. National Committee for Quality Assurance. Diabetes Recognition Program. 2011.

  27. Thom DH, Bloch DA, Segal ES. An intervention to increase patients’ trust in their physicians. Stanford trust study physician group. Acad Med. 1999;74(2):195–198.

    Article  PubMed  CAS  Google Scholar 

  28. Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, et al. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care. 2007;30(4):807–812.

    Article  PubMed  Google Scholar 

  29. Kaplan SH, Billimek J, Sorkin DH, Ngo-Metzger Q, Greenfield S. Who can respond to treatment? Identifying patient characteristics related to heterogeneity of treatment effects. Medical Care. 2010;48(6):S9–S16.

    Article  PubMed  Google Scholar 

  30. McEwen LN, Kim C, Ettner SL, Herman WH, Karter AJ, Beckles GL, et al. Competing demands for time and self-care behaviors, processes of care, and intermediate outcomes among people with diabetes. Diabetes Care. 2011.

  31. Ho PM, Rumsfeld JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166(17):1836–1841.

    Article  PubMed  Google Scholar 

  32. Schectman JM, Nadkarni MM, Voss JD. The association between diabetes metabolic control and drug adherence in an indigent population. Diabetes Care. 2002;25(6):1015–1021.

    Article  PubMed  Google Scholar 

  33. Rhee MK, Slocum W, Ziemer DC, Culler SD, Cook CB, El-Kebbi IM, et al. Patient adherence improves glycemic control. Diabetes Educ. 2005;31(2):240–250.

    Article  PubMed  Google Scholar 

  34. Adams AS, Trinacty CM, Zhang F, Kleinman K, Grant RW, Meigs JB, et al. Medication adherence and racial differences in A1C control. Diabetes Care. 2008;31(5):916–921.

    Article  PubMed  Google Scholar 

  35. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA. 1998;279(21):1703–1708.

    Article  PubMed  CAS  Google Scholar 

  36. Lantz PM, House JS, Mero RP, Williams DR. Stress, life events, and socioeconomic disparities in health: results from the Americans’ Changing Lives Study. J Health Soc Behav. 2005;46(3):274–288.

    Article  PubMed  Google Scholar 

  37. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60–76.

    Article  Google Scholar 

  38. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475–482.

    Article  PubMed  Google Scholar 

  39. Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, Crigler B, et al. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA. 2004;292(14):1711–1716.

    Article  PubMed  CAS  Google Scholar 

  40. Kaplan SH, Dukes KA, Sullivan LM, Tripp TJ, Greenfield S. Is passivity a risk factor for poor health outcomes? J Gen Int Med. 1996;11(Supp 1):76.

    Google Scholar 

  41. Talbot F, Nouwen A, Gingras J, Gosselin M, Audet J. The assessment of diabetes-related cognitive and social factors: the multidimensional diabetes questionnaire. J Behav Med. 1997;20(3):291–312.

    Article  PubMed  CAS  Google Scholar 

  42. Greenfield S, Kaplan SH, Silliman RA, Sullivan L, D’Agostino R, Manning W, et al. The uses of outcomes research for medical effectiveness, quality of care and reimbursement in type II diabetes. Diabetes Care. 1994;17(Supp 1):32–39.

    PubMed  Google Scholar 

  43. Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996;10(4):282–298.

    Article  PubMed  CAS  Google Scholar 

  44. Suls J, Rothman A. Evolution of the biopsychosocial model: prospects and challenges for health psychology. Health Psychol. 2004;23(2):119–125.

    Article  PubMed  Google Scholar 

  45. AHRQ: Medical Expenditure Panel Survey.

  46. Safran DGS, Kosinski M, Tarlov AR, Rogers WH, Taira DAS, Lieberman N, et al. The primary care assessment survey: tests of data quality and measurement performance. Medical Care. 1998;36(5):728–39.

    Article  PubMed  CAS  Google Scholar 

  47. Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, et al. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care. 2007;30(4):807–812.

    Article  PubMed  Google Scholar 

  48. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 2011;34(Supplement 1):S11–S61.

    Article  Google Scholar 

  49. Swanson D, Norcini J, Kaplan S, Carter W, Ware J, and the ABIM PSQ Investigators. Final Report of the PSQ Project. Philadelphia: American Board of Internal Medicine; 1989.

    Google Scholar 

  50. Greenfield S, Billimek J, Kaplan SH. The total illness burden index: a patient-reported summary measure of multimorbidity. In: Preedy VR, Watson RR, eds. Handbook of Disease Burdens and Quality of Life Measures. Heidelberg: Springer; 2009.

    Google Scholar 

  51. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.

    Article  Google Scholar 

  52. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–483.

    Article  PubMed  Google Scholar 

  53. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston: Nimrod; 1993.

    Google Scholar 

  54. California Health Interview Survey. CHIS 2003 Methodology Series: Report 2–2003 Data Collection Methods. Available at http://healthpolicy.ucla.edu/chis/design/Documents/CHIS2003_method2.pdf. Accessed on April 2, 2013.

  55. Stephens MA, Fekete EM, Franks MM, Rook KS, Druley JA, Greene K. Spouses’ use of pressure and persuasion to promote osteoarthritis patients’ medical adherence after orthopedic surgery. Health Psychol. 2009;28(1):48–55.

    Article  PubMed  Google Scholar 

  56. Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med. 2005;22(10):1379–1385.

    Article  PubMed  CAS  Google Scholar 

  57. Kaplan SH, Sullivan LM, Dukes KA, Khan A, Wilson IB, Wagner E, et al. Underestimating the hassle factor. Using disease-specific vs. general health status measures to evaluate medical care. Int J Qual Health Care. 1996;8:412–413.

    Article  Google Scholar 

  58. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33(12):1176–1187.

    Article  PubMed  CAS  Google Scholar 

  59. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124(5):497–504.

    Article  PubMed  CAS  Google Scholar 

  60. Thom DH, Ribisl KM, Stewart AL, Luke DA. Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians. Med Care. 1999;37(5):510–517.

    Article  PubMed  CAS  Google Scholar 

  61. Thom DH, Kravitz RL, Bell RA, Krupat E, Azari R. Patient trust in the physician: relationship to patient requests. Fam Pract. 2002;19(5):476–483.

    Article  PubMed  Google Scholar 

  62. Pierre-Jacques M, Safran DG, Zhang F, Ross-Degnan D, Adams AS, Gurwitz J, et al. Reliability of new measures of cost-related medication nonadherence. Med Care. 2008;46(4):444–448.

    Article  PubMed  Google Scholar 

  63. Soumerai SB. Cost-related medication nonadherence among elderly and disabled medicare beneficiaries: a national survey 1 year before the medicare drug benefit. Arch Intern Med. 2006;166(17):1829–1835.

    Article  PubMed  Google Scholar 

  64. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the medical outcomes study. J Behav Med. 1992;15(5):447–468.

    Article  PubMed  CAS  Google Scholar 

  65. Toobert DJ, Glasgow RE. Assessing diabetes self-management: the summary of diabetes self-care activities questionnaire. In: Bradley C, ed. Handbook of Psychology and Diabetes. Newark: Harwood Academic Publishers; 1994:355–356.

    Google Scholar 

  66. Woodruff DJ, Feldt LS. Tests for equality of several alpha coefficients when their sample estimates are dependent. Psychometrika. 1986;51:393–413.

    Article  Google Scholar 

  67. Bland JM, Altman DG. Statistics notes: multiple significance tests: the Bonferroni method. BMJ. 1995;310(6973):170.

    Article  PubMed  CAS  Google Scholar 

  68. Cook BL, McGuire TG, Zaslavsky AM. Measuring racial/ethnic disparities in health care: methods and practical issues. Health Serv Res. 2012;47(3 Pt 2):1232–1254.

    Article  PubMed  Google Scholar 

  69. Adams RJ, Smith BJ, Ruffin RE. Impact of the physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol. 2001;86(3):263–271.

    Article  PubMed  CAS  Google Scholar 

  70. Arora NK, Weaver KE, Clayman ML, Oakley-Girvan I, Potosky AL. Physicians’ decision-making style and psychosocial outcomes among cancer survivors. Patient Educ Couns. 2009;77(3):404–412.

    Article  PubMed  Google Scholar 

  71. Maly RC, Stein JA, Umezawa Y, Leake B, Douglas AM. Racial/ethnic differences in breast cancer outcomes among older patients: effects of physician communication and patient empowerment. Health Psychol: Off J Div Health Psychol Am Psychol Assoc. 2008;27(6):728–736.

    Google Scholar 

  72. Sleath B, Ayala GX, Washington D, Davis S, Williams D, Tudor G, et al. Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits. Patient Educ Couns. 2011;85(2):286–289.

    Article  PubMed  Google Scholar 

  73. Cooper LA, Roter DL. Patient–provider communication: the effect of race and ethnicity on process and outcomes of healthcare. In: Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003:552–593.

    Google Scholar 

  74. Parchman ML, Zeber JE, Palmer RF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Ann Fam Med. 2010;8(5):410–417.

    Article  PubMed  Google Scholar 

  75. Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17(4):243–252.

    Article  PubMed  Google Scholar 

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Acknowledgements

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This work was supported by The Robert Wood Johnson Foundation (Grants # 1051084 and #59758), Princeton, New Jersey, The NovoNordisk Foundation, Corporate Diabetes Programmes, Novo Nordisk, Bagsvaerd, Denmark, and the National Institute of Diabetes, Digestive and Kidney Diseases (R18DK69846 and K01DK078939), Building 31. Rm 9A06, 31 Center Drive, MSC 2560 Bethesda, MD 20892–2560, USA.

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The authors declare that they do not have a conflict of interest.

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Correspondence to Sherrie H. Kaplan PhD, MPH.

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Kaplan, S.H., Billimek, J., Sorkin, D.H. et al. Reducing Racial/Ethnic Disparities in Diabetes: The Coached Care (R2D2C2) Project. J GEN INTERN MED 28, 1340–1349 (2013). https://doi.org/10.1007/s11606-013-2452-y

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