Gender differences across racial and ethnic groups in the quality of care for diabetes

High-quality care for diabetes is based on proper prevention, coordination of care among a multidisciplinary team of health care professionals, enhanced patient–provider relationships, and patient self-management skills. This paper discusses gender differences across racial and ethnic groups in the quality of care for type 2 diabetes according to 10 measures defined by the National Healthcare Quality Report and the National Healthcare Disparities Report. These measures include 5 process measures and one composite measure derived from the Medical Expenditure Panel Survey and 4 outcome measures derived from the Healthcare Cost and Utilization Project. National rates for 2 process measures—measurement of HbA1c (women 89.70% versus men 90.10%) and lipid profile (women 92.9% versus men 95.3%)—are high, but only 28.9% of women and 33.9% of men with diabetes received all 5 recommended process measures (HbA1c, lipid profile, eye exam, foot exam, and influenza immunization). Screening rates for retinal and foot exams and influenza immunization should be improved for all, but the need is particularly urgent for Hispanics and non-Hispanic blacks. Women and men have similar rates of hospital admissions for uncontrolled diabetes, but rates for lower extremity amputations were higher for men, particularly non-Hispanic blacks and Hispanics. Avoidable hospitalizations for diabetes decreased as income increased across racial/ethnic groups, but other factors (e.g., quality of primary care, age, relationship with providers, patients’ self-management skills) may influence such rates. Moreover, any improvements in the diabetes outcomes measures may lag many years behind any measurable improvements in quality of care. Well-designed interventions that reallocate resources for diabetes self-care should be developed to ensure that gender differences are addressed across racial/ethnic groups. Because much of this care involves the management of risk factors, self-management education should be tailored to the lifestyles and beliefs specific to gender and racial/ethnic groups.

Introduction

Diabetes is the sixth leading cause of death in the United States, with mortality rates for adults with diabetes being twice that of the general population (American Diabetes Association 2003a, American Diabetes Association 2003b). In 2005, 20.8 million people had diabetes with 14.6 million people diagnosed and 6.2 million undiagnosed (Centers for Disease Control and Prevention [CDC], 2005). Diabetes affects 9.7 million women and 10.9 million men age 20 and over. Prevalence for the various racial/ethnic groups is: non-Hispanic whites (13.1 million), non-Hispanic blacks (3.2 million), Hispanic/Latino Americans (2.5 million), and American Indians/Alaska Natives (117,994). Prevalence is also high among people with lower educational levels. Diabetes prevalence in the general population is projected to increase by 44% by 2020: 107% for Hispanics and 56% for older adults (American Diabetes Association 2002, American Diabetes Association 2003b). Diabetes-related mortality rates are higher among blacks, Native Americans, and Hispanics (Mokdad et al., 2000). Diabetes is associated with a range of other illnesses and is a major risk factor for cardiovascular disease. People with diabetes are at increased risk for stroke, ischemic heart disease, peripheral vascular disease, and neuropathy (American Diabetes Association 2002, American Diabetes Association 2003b). Blacks have higher rates of serious complications from diabetes, including higher rates of end-stage renal disease and lower extremity amputation (Centers for Disease Control and Prevention 1999, Guadagnoli et al 1995, Gornick et al 1996).

Diabetes is a public health and economic concern. The total cost of the disease in the United States for 2002 was estimated at $132 billion, of which $91.8 billion was attributed to direct medical costs and $40 billion to indirect costs owing to disability, work loss, and premature mortality (American Diabetes Association, 2003a).

Diabetes is a preventable disease that can be effectively managed to delay or avoid its complications (Centers for Disease Control and Prevention (CDC) 2004, Heisler et al 2003, Hill-Briggs et al 2003). To identify gaps in care and avoid unnecessary expense, monitoring the ongoing quality of health care in patients with diabetes is crucial. Despite evidence currently available on the best practices in diabetes care, there is still wide variation in diagnostic evaluation, use of preventive services, and the quality and extent of disease management (American Diabetes Association 2003b, Diabetes Prevention Program Research Group 2002, Dallo and Weller 2003).

The purpose of this study is to investigate whether gender differences across racial/ethnic groups exist in the quality of care received by people who suffer from type 2 diabetes. The quality of care for diabetes is evaluated according to 10 process and outcomes measures as defined by the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) (Agency for Healthcare Research and Quality 2005a, Agency for Healthcare Research and Quality 2005b, Agency for Healthcare Research and Quality 2004a, Agency for Healthcare Research and Quality 2004b). The paper’s unique contribution is that it goes beyond the scope of the national reports by performing additional data analysis by gender within racial/ethnic groups. Our findings provide the basis for future development of gender- and/or race/ethnicity-specific strategies to help close the gaps in diabetes care.