June 13, 2008 Primary care physicians caring for patients with diabetes have worse outcomes among their black patients than their white patients, reports a new study conducted by Harvard Vanguard Medical Associates.
"Many studies have described racial differences in diabetes care across the American health care system, but there is very limited information regarding the potential role of individual physicians," says Thomas Sequist, MD, MPH, primary care physician at Harvard Vanguard Medical Associates and lead author of the study. "This study suggests that the problem of racial disparities in diabetes care is pervasive in physician practices, and not limited to a small cluster of physicians providing particularly low quality care."
A related study published in the May 2008 issue of the Journal of General Internal Medicine, also led by Sequist, found that 88 percent of physicians surveyed acknowledged the existence of racial disparities in diabetes care within the U.S. health care system. However, only 40 percent of these same physicians reported perceiving disparities among patients they personally treat. This discrepancy illustrates the need for widespread interventions, including those that increase awareness of the importance of racial disparities within the local health care environment.
Previous studies have examined the role of hospitals, health plans, and geography as mediators of racial disparities, but little is known about the role of variation among individual physicians. Sequist's Archives study included 90 primary care physicians caring for at least five white and five black adults with diabetes across 13 ambulatory centers. The study found that white patients were significantly more likely than black patients to achieve control of three critical health measures for diabetes patients: hemoglobin A1c, LDL cholesterol, and blood pressure.
For white patients compared to black patients, 47% were able to achieve control of their hemoglobin A1c levels (<7%), versus 39%; 57% were able to control LDL cholesterol (<11 mg/dL) versus 45%; and 30% were able to control their blood pressure (<130/80 mmHg) versus 24%.
Results indicated that adjustment for patients' age, sex, household income, and health insurance status played a substantial role in explaining disparities in control of hemoglobin A1c and LDL cholesterol, accounting for 13 to 38 percent of the observed disparity. However, significant disparities remained even after correcting for these factors.
Black patients were not disproportionately cared for by physicians with lower overall scores for diabetes care. Rather, black patients experienced less ideal outcomes than white patients within most physician panels. The authors also found no association between the magnitude of the racial disparities in a physician's panel of patients and the number of black patients treated by that doctor.
"Racial disparities in diabetes outcomes are spread across entire health care systems, requiring the implementation of system-wide solutions," said John Ayanian, MD, MPP, co-author of the study and professor of medicine and health care policy at Harvard Medical School and Brigham and Women's Hospital.
"One important potential use of these findings is to educate physicians regarding the importance of racial disparities in their own local health care practice," said Sequist, who is also an assistant professor of medicine and health care policy at Harvard Medical School and Brigham and Women's Hospital. "Understanding the underlying causes of racial disparities in diabetes outcomes will enable health systems to develop solutions to eliminate these disparities."
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- Thomas D. Sequist, MD, MPH; Garrett M. Fitzmaurice, ScD; Richard Marshall, MD; Shimon Shaykevich, MS; Dana Gelb Safran, ScD; John Z. Ayanian, MD, MPP. Physician Performance and Racial Disparities in Diabetes Mellitus Care. Archives of Internal Medicine, 2008;168(11):1145-1151 [link]
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