Cram Peter, Saag Kenneth G, Lou Yiyue, Edmonds Stephanie W, Hall Sylvie F, Roblin Douglas W, Wright Nicole C, Jones Michael P, Wolinsky Fredric D
*Department of Medicine, University of Toronto †Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, ON, Canada ‡Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA §Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL Departments of ∥Biostatistics ¶Health Management and Policy, University of Iowa College of Public Health #University of Iowa College of Nursing **CADRE, Iowa City VA Healthcare System, Iowa City, IA ††Kaiser Permanente ‡‡School of Public Health, Georgia State University, Atlanta, GA §§Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL.
Med Care. 2017 Jun;55(6):561-568. doi: 10.1097/MLR.0000000000000718.
Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care.
DESIGN, SUBJECTS, AND MEASURES: We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors.
Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation.
Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.
要确定观察到的医疗保健差异是否可被称为差距，需要在对相关患者、医疗服务提供者和卫生系统因素进行调整后，差异仍然存在。我们研究了直接向患者提供双能X线吸收测定法（DXA）检测结果是否可能减少或消除骨质疏松症相关医疗保健中的种族差异。
设计、研究对象与测量方法：我们分析了2012年2月至2014年8月期间在参与DXA结果通知后患者激活（PAADRN）实用临床试验（ClinicalTrials.gov标识符：NCT-01507662）的2个卫生系统中接受DXA检测的3484名白人女性和1041名黑人女性的数据。我们在DXA检测后12周和52周检查了7项与骨骼健康相关的结果：（1）患者是否正确识别其DXA基线结果；（2）患者是否接受符合指南的骨质疏松症药物治疗；（3）与骨质疏松症相关的满意度；（4）骨质疏松症知识；（5和6）运动和饮食方面的骨质疏松症自我效能感；以及（7）患者激活情况。我们研究了在对患者、医疗服务提供者和卫生系统因素进行调整后，白人和黑人在结果方面未经调整的差异是否仍然存在。
平均年龄为66.5岁，29%为黑人。在基线时，黑人女性受教育程度较低，健康状况较差，且报告有骨质疏松症病史的可能性较小（所有P<0.001）。在未经调整的分析中，黑人女性正确识别其实际DXA结果的可能性较小，接受符合指南治疗的可能性较大，且患者激活情况相似。在对患者人口统计学、基线健康状况和其他因素进行调整后，黑人女性仍然不太可能知道其实际DXA结果，接受符合指南治疗的可能性也较小，但黑人女性的患者激活程度更高。
对患者和医疗服务提供者层面因素的调整可以改变对种族差异的看法，揭示新的差距，并为其他差异提供解释。
