Gary Tiffany L, McGuire Maura, McCauley Jeanne, Brancati Frederick L
Department of Epidemiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, USA.
Dis Manag. 2004 Spring;7(1):25-34. doi: 10.1089/109350704322918970.
The excess risk of diabetic complications in African Americans may be due to poor glycemic control arising from suboptimal use and/or quality of diabetes-related health care. However, little is known about racial differences in these factors, particularly in urban populations. We conducted a cross-sectional study using medical claims and encounter data on 1,106 adults with diabetes aged > or =30 years who were members of an urban managed care organization in capitated health plans. We examined health care and routine hemoglobin A(1c) (HbA(1c)) testing in a biracial cohort for 12 months. We then followed individuals for an additional 12 months, using a retrospective cohort design, to determine how this health care predicted subsequent emergency room visits. On average, compared with their white counterparts, African Americans had fewer primary care visits (85% vs. 91% with four or more visits) and fewer HbA(1c) tests (56% vs. 68% with two or more HbA(1c) tests) (all P < 0.05). Likewise, in the subset who underwent one or more HbA(1c) measurement (n = 855), African Americans displayed poorer glycemic control (HbA(1c) 9.1 +/- 2.9%) than whites (8.5 +/- 2.2%; P = 0.001). In multivariate analyses, racial differences in visit frequency and HbA(1c) testing were attenuated by adjustment for age, sex, and type of capitated plan and did not remain statistically significant. The relationship of health care to subsequent emergency room visits differed by race; in African Americans, fewer primary care visits and HbA(1c) tests predicted greater risk of emergency room visits. Even in a capitated, managed care setting, urban African Americans with diabetes are less likely than their white counterparts to undergo routine primary care visits and laboratory testing and are more likely to have suboptimal glycemic control. Differences in age, sex, and insurance type seemed to explain some of the disparities. Future research should determine the individual contributions of physician, patient, and system factors to the racial disparities in health care.
非裔美国人糖尿病并发症的额外风险可能归因于糖尿病相关医疗保健使用不当和/或质量欠佳导致的血糖控制不佳。然而，对于这些因素中的种族差异，尤其是城市人群中的差异，我们知之甚少。我们开展了一项横断面研究，利用了1106名年龄≥30岁的成年糖尿病患者的医疗理赔和就诊数据，这些患者是一家城市管理式医疗组织中按人头付费健康计划的成员。我们在一个双种族队列中对医疗保健和常规糖化血红蛋白（HbA1c）检测进行了为期12个月的研究。然后，我们采用回顾性队列设计对个体进行了另外12个月的随访，以确定这种医疗保健如何预测随后的急诊室就诊情况。平均而言，与白人相比，非裔美国人的初级保健就诊次数较少（四次或更多次就诊的比例分别为85%和91%），HbA1c检测次数也较少（两次或更多次HbA1c检测的比例分别为56%和68%）（所有P<0.05）。同样，在接受了一次或更多次HbA1c测量的亚组（n=855）中，非裔美国人的血糖控制情况（HbA1c为9.1±2.9%）比白人（8.5±2.2%；P=0.001）更差。在多变量分析中，通过对年龄、性别和按人头付费计划类型进行调整，就诊频率和HbA1c检测方面的种族差异有所减弱，且不再具有统计学显著性。医疗保健与随后急诊室就诊之间的关系因种族而异；在非裔美国人中，较少的初级保健就诊次数和HbA1c检测次数预示着更高的急诊室就诊风险。即使在按人头付费的管理式医疗环境中，患有糖尿病的城市非裔美国人比他们的白人同行接受常规初级保健就诊和实验室检测的可能性更小，血糖控制不佳的可能性更大。年龄、性别和保险类型的差异似乎解释了部分差异。未来的研究应该确定医生、患者和系统因素对医疗保健中种族差异的个体贡献。
