Systematic care to reduce ethnic disparities in diabetes care

When the Process Is the Problem: Racial/Ethnic and Language Disparities in Care Management

OBJECTIVES

Achieving health equity requires addressing disparities at every level of care delivery. Yet, little literature exists examining racial/ethnic disparities in processes of high-risk care management, a foundational tool for population health. This study sought to determine whether race, ethnicity, and language are associated with patient entry into and service intensity within a large care management program.

DESIGN

Retrospective cohort study.

METHODS

Subjects were 23,836 adult patients eligible for the program between 2015 and 2018. Adjusting for demographics, utilization, and medical risk, we analyzed the association between race/ethnicity and language and outcomes of patient selection, enrollment, care plan completion, and care management encounters.

RESULTS

Among all identified as eligible by an algorithm, Asian and Spanish-speaking patients had significantly lower odds of being selected by physicians for care management [OR 0.74 (0.58-0.93), OR 0.79 (0.64-0.97)] compared with White and English-speaking patients, respectively. Once selected, Hispanic/Latino and Asian patients had significantly lower odds compared to White counterparts of having care plans completed by care managers [OR 0.69 (0.50-0.97), 0.50 (0.32-0.79), respectively]. Patients speaking languages other than English or Spanish had a lower odds of care plan completion and had fewer staff encounters than English-speaking counterparts [OR 0.62 (0.44-0.87), RR 0.87 (0.75-1.00), respectively].

CONCLUSIONS

Race/ethnicity and language-based disparities exist at every process level within a large health system's care management program, from selection to outreach. These results underscore the importance of assessing for disparities not just in outcomes but also in program processes, to prevent population health innovations from inadvertently creating new inequities.

Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities

Background

About 40% of all health burden in New Zealand is due to cancer, cardiovascular disease, and type 2 diabetes/obesity. Outcomes for Māori (indigenous people) are significantly worse than non-Maori; these inequities mirror those found in indigenous communities elsewhere. Evidence-based interventions with established efficacy may not be effective in indigenous communities without addressing specific implementation challenges. We present an implementation framework for interventions to prevent and treat chronic conditions for Māori and other indigenous communities.

Theoretical framework

The He Pikinga Waiora Implementation Framework has indigenous self-determination at its core and consists of four elements: cultural-centeredness, community engagement, systems thinking, and integrated knowledge translation. All elements have conceptual fit with Kaupapa Māori aspirations (i.e., indigenous knowledge creation, theorizing, and methodology) and all have demonstrated evidence of positive implementation outcomes.

Applying the framework

A coding scheme derived from the Framework was applied to 13 studies of diabetes prevention in indigenous communities in Australia, Canada, New Zealand, and the United States from a systematic review. Cross-tabulations demonstrated that culture-centeredness (p = .008) and community engagement (p = .009) explained differences in diabetes outcomes and community engagement (p = .098) explained difference in blood pressure outcomes.

Implications and conclusions

The He Pikinga Waiora Implementation Framework appears to be well suited to advance implementation science for indigenous communities in general and Māori in particular. The framework has promise as a policy and planning tool to evaluate and design effective interventions for chronic disease prevention in indigenous communities.

What supports are needed by New Zealand primary care to improve equity and quality?

While some primary care practices have found ways to deliver quality care more equitably to their Māori and Pacific patients, others have struggled to get started or be successful. Quality Symposium attendees shared their views on barriers and success factors, both within the practice and beyond. When practices have collaborated and used their own ethnic-specific data in quality improvement techniques, they have improved Māori and Pacific health and equity. Attendees asked for greater practical support and guidance from the profession and sector. They report a funding gap for services needed by their patients to enable primary care to deliver equitable services for Māori and Pacific people.

Limited evidence to assess the impact of primary health care system or service level attributes on health outcomes of Indigenous people with type 2 diabetes: a systematic review

BACKGROUND

To describe reported studies of the impact on HbA1C levels, diabetes-related hospitalisations, and other primary care health endpoints of initiatives aimed at improving the management of diabetes in Indigenous adult populations of Australia, Canada, New Zealand and the United States.

METHOD

Systematic literature review using data sources of MEDLINE, Embase, the Cochrane Library, CINHAL and PsycInfo from January 1985 to March 2012. Inclusion criteria were a clearly described primary care intervention, model of care or service, delivered to Indigenous adults with type 2 diabetes reporting a program impact on at least one quantitative diabetes-related health outcome, and where results were reported separately for Indigenous persons. Joanna Briggs Institute critical appraisal tools were used to assess the study quality. PRISMA guidelines were used for reporting.

RESULTS

The search strategy retrieved 2714 articles. Of these, 13 studies met the review inclusion criteria. Three levels of primary care initiatives were identified: 1) addition of a single service component to the existing service, 2) system-level improvement processes to enhance the quality of diabetes care, 3) change in primary health funding to support better access to care. Initiatives included in the review were diverse and included comprehensive multi-disciplinary diabetes care, specific workforce development, systematic foot care and intensive individual hypertension management. Twelve studies reported HbA1C, of those one also reported hospitalisations and one reported the incidence of lower limb amputation. The methodological quality of the four comparable cohort and seven observational studies was good, and moderate for the two randomised control trials.

CONCLUSIONS

The current literature provides an inadequate evidence base for making important policy and practice decisions in relation to primary care initiatives for Indigenous persons with type 2 diabetes. This reflects a very small number of published studies, the general reliance on intermediate health outcomes and the predominance of observational studies. Additional studies of the impacts of primary care need to consider carefully research design and the reporting of hospital outcomes or other primary end points. This is an important question for policy makers and further high quality research is needed to contribute to an evidence-base to inform decision making.

Culturally competent interventions in Type 2 diabetes mellitus management: an equity-oriented literature review

OBJECTIVES

Although, culturally competent (CC) interventions aim to reduce health inequalities for ethnic minorities, they have been criticized on the grounds that they increase prejudice and stereotyping. It remains unclear whether CC interventions really can reduce health inequalities among ethnic minorities. The purpose of this review is to assess whether CC interventions in the management of Type 2 diabetes mellitus (T2DM) match the recommendations to reduce health inequalities.

DESIGN

We identified CC interventions relating to T2DM among ethnic minority patients in the literature published between 2005 and 2011. Data were analyzed according to an equity-oriented framework. Each study was given a score based on its congruence with the reduction of health inequalities amongst ethnic minorities.

RESULTS

We reviewed 137 papers and found 61 studies that met the inclusion criteria. Most interventions focused on the individual level and the modification of patients' health behavior. Very few addressed the sociopolitical level. A minority of the studies acknowledged the role of socioeconomic deprivation in ethnic health inequalities. Half of the studies contained no information about the socioeconomic status of the patients. The patients receiving the interventions were socioeconomically deprived. Only 10 studies compared ethnic minority groups to majority groups. Thirty-three studies had a very low average congruence score. The highest score of congruence was achieved by one study.

CONCLUSION

Overall, CC interventions addressing T2DM are not congruent with the reduction of ethnic health inequalities. The future of CC interventions may involve going one step further and going back to basic tenets of cultural competence: the integration of difference, whatever its source, into the delivery of fair health care for patients.

Global Diabetes Survey--an annual report on quality of diabetes care

Adequate quality of diabetes care and the best concept for the implementation of national diabetes plans remain controversial. In September 2011 the United Nations High Level Meeting on Non Communicable Diseases agreed on a consensus that national plans for the prevention and control of diabetes should be developed, implemented and monitored. The Global Diabetes Survey (GDS) is a standardised, annual, global questionnaire that will be used to assess responses of representatives from 19 diabetes-related stakeholder groups. It was designed with the goal of generating an annual report on the quality of national diabetes care and to compare findings from different regions and countries. The findings will be freely available for everyone's use and will be used to inform politicians and stakeholders to encourage the improvement of the quality of diabetes care in its medical, economical, structural and political dimensions.

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

AIM

The incidence of end-stage kidney disease (ESKD) has been increasing worldwide, with increasing numbers of older people, people with diabetic nephropathy and indigenous people. We investigated the incidence of renal replacement therapy (RRT) in Australia and New Zealand (NZ) to better understand the causes of these effects.

METHODS

Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)registry and relevant population data were used to investigate the incidence of RRT in five demographic groups: Indigenous and non-indigenous Australians, Māori, Pacific Islanders and other New Zealanders, as well as differences between genders and age groups.

RESULTS

The numbers of patients commencing RRT each year increased by 321% between 1990 and 2009. This increase was largely driven by increases in patients with diabetic nephropathy. In 2009 35% of new patients had ESKD resulting from diabetic nephropathy 92% of which were type 2. Indigenous Australians, and Māori and Pacific people of NZ have elevated risks of commencing RRT due to diabetic nephropathy, although the risks compared with non-indigenous Australians have decreased over time. A small element of lead time bias also contributed to this increase. Males are more likely to commence RRT due to diabetes than females, except among Australian Aborigines, where females are more at risk. There is a marked increase in older, more comorbid patients.

CONCLUSIONS

Patterns of incident renal replacement therapy strongly reflect the prevalence of diabetes within these groups. In addition, other factors such as reduced risk of dying before reaching ESKD, and increased acceptance of older and sicker patients are also contributing to increases in incidence of RRT.