Trivedi Amal N, Zaslavsky Alan M, Schneider Eric C, Ayanian John Z
Department of Community Health, Brown University, Providence, RI, USA.
JAMA. 2006 Oct 25;296(16):1998-2004. doi: 10.1001/jama.296.16.1998.
Overall quality of care and racial disparities in quality are important and related problems in health care, but their relationship has not been well studied. In the Medicare managed care program, broad improvements in quality have been accompanied by reduced racial gaps in processes of care, but substantial disparities in outcomes have persisted.
To assess variations among Medicare health plans in overall quality and racial disparity in 4 Health Plan Employer and Data Information Set (HEDIS) outcome measures, to determine whether high-performing plans exhibit smaller racial disparities, and to identify plans with high quality and low disparity.
DESIGN, SETTING, AND PATIENTS: We assessed the relationship between quality and racial disparity using multilevel multivariable regression models. The study sample included 431,573 individual-level observations in 151 Medicare health plans from 2002 to 2004.
Hemoglobin A(1c) of less than 9.5% or less than 9.0% for enrollees with diabetes; low-density lipoprotein cholesterol level of less than 130 mg/dL for enrollees with diabetes or after a coronary event; and blood pressure of less than 140/90 mm Hg for enrollees with hypertension.
Clinical performance on HEDIS outcome measures was 6.8% to 14.4% lower for black enrollees than for white enrollees (P<.001 for all). For each measure, more than 70% of this disparity was due to different outcomes for black and white individuals enrolled in the same health plan rather than selection of black enrollees into lower-performing plans. Health plans varied substantially in both overall quality and racial disparity on each of the 4 outcome measures. Adjusted correlations between overall quality and racial disparity were small and not statistically significant, ranging from 0.01 (blood pressure control) to -0.21 (cholesterol control in diabetes). Only 1 health plan achieved both high quality and low disparity on more than 1 measure.
In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports.
医疗服务的总体质量以及质量方面的种族差异是医疗保健领域重要且相关的问题，但它们之间的关系尚未得到充分研究。在医疗保险管理式医疗计划中，质量的广泛改善伴随着医疗过程中种族差距的缩小，但结果方面的巨大差异依然存在。
评估医疗保险健康计划在4项健康计划雇主与数据信息集（HEDIS）结果指标方面的总体质量差异和种族差异，确定表现优异的计划是否存在较小的种族差异，并识别出高质量且低差异的计划。
设计、设置与患者：我们使用多层次多变量回归模型评估质量与种族差异之间的关系。研究样本包括2002年至2004年期间151个医疗保险健康计划中的431,573个个体层面的观察数据。
糖尿病参保者血红蛋白A1c低于9.5%或低于9.0%；糖尿病参保者或冠心病事件后低密度脂蛋白胆固醇水平低于130mg/dL；高血压参保者血压低于140/90mmHg。
黑人参保者在HEDIS结果指标上的临床表现比白人参保者低6.8%至14.4%（所有指标P<0.001）。对于每项指标，这种差异的70%以上是由于同一健康计划中黑人和白人个体的不同结果，而非黑人参保者被选入表现较差的计划。在4项结果指标中的每一项上，健康计划在总体质量和种族差异方面都存在很大差异。总体质量与种族差异之间的调整后相关性很小且无统计学意义，范围从0.01（血压控制）到-0.21（糖尿病患者胆固醇控制）。只有1个健康计划在超过1项指标上实现了高质量和低差异。
在医疗保险健康计划中，差异广泛存在且与医疗服务的总体质量仅存在微弱关联。因此，针对结果指标的种族差异的特定计划绩效报告将提供标准HEDIS报告目前未传达的有用信息。
