Reducing Racial/Ethnic Disparities in Diabetes: The Coached Care (R2D2C2) Project
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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 nonHispanic 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.
INTRODUCTION
Despite comparable quality of the process of care1–3 and many efforts to change features of the healthcare delivery system,4–7 disparities in the outcomes of care for type 2 diabetes persist and have not changed substantially over the past 10 years.8–13 Empirically tested hypotheses offered to explain the persistence of racial/ethnic disparities have included a broad spectrum of variables, from societal characteristics (e.g. limited access to healthcare services and resources10,14–16), characteristics of the healthcare system (e.g. continuity of care,17 access to specialists,18 availability of interpreters19), characteristics and behaviors of healthcare providers (e.g. quality of technical and interpersonal care,20–27 clinical ‘inertia’28), to characteristics and behaviors of patients (e.g. illness burden,29 competing demands,30 adherence to treatment,31–34 health habits,35,36 social environment,37 health literacy,38,39 and
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