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Physicians may need more than cultural competency training to combat racial disparities in diabetes care
1-05-10
Providing cultural competency training and performance report cards for physicians may not be enough to significantly improve the health of African-American diabetic patients, according to a study published in the January 5th, 2009 issue of the Annals of Internal Medicine. Support for this study was provided by a grant from the Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change program.
“Cultural competency training for physicians caring for minority patients is viewed as a promising strategy for addressing racial/ethnic disparities, but there is little evidence on what training programs should look like and whether they are effective,” said Thomas Sequist, MD, MPH, primary care physician at Harvard Vanguard Medical Associates, and lead author of the study. “This study shows that cultural competency training and performance feedback will need to be combined with other solutions to improve care for black patients. The individual physician may have limited ability to affect meaningful change when confronted by significant socio-economic determinants of disparities – such as lower incomes and inadequate access to affordable nutrition among African American patients.”
The latest study examined the combined effects of cultural competency training and race-stratified performance reports for 124 primary care clinicians on 1) their awareness of racial disparities in diabetes care, and 2) quality measures among their African-American diabetic patients. The study found that while the 61 physicians exposed to the training and monthly feedback were significantly more likely to report awareness of racial disparities in diabetes care, clinical outcomes did not improve significantly for their patients.
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Study Diabetes Patients
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Control Diabetes Patients
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Hemoglobin A1c <7%
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48%
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45%
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LDL Cholesterol <100 mg/dL
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48%
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49%
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Blood Pressure <130/80 mmHg
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23%
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25%
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Physicians who underwent training were more likely to acknowledge the presence of racial disparities within their local health center (70% vs. 51%) and among their own patients (63% vs. 43%), compared to the physician group who received no training or performance feedback. However, the physicians exposed to the intervention became significantly less likely to consider cultural competency and clinical awareness of racial disparities to be a “very effective” intervention in reducing racial disparities.
The physician study group, in addition to nurse practitioners and physician assistants, drawn from Harvard Vanguard Medical Associates, participated in an intense, 12 month program of cultural competency training focused on specific goals of understanding attitudes of trust and bias, increasing knowledge regarding health disparities and gaining skills to improve delivery of cross-cultural care. Recommendations tailored to caring for black diabetic patients were provided on a monthly basis, accompanied by monthly race-stratified clinical performance results.
A related study published in the May 2008 issue of the Journal of General Internal Medicine, also led by Sequist, found that 88 percent of physicians surveyed acknowledged the existence of racial disparities in diabetes care within the U.S. health care system. However, fewer than 40 percent of those surveyed reported disparities among patients they personally treat, despite the documentation of such differences. This discrepancy suggested the need for widespread interventions, including those that increase awareness of the importance of racial disparities within the local health care environment.
Previous studies have examined the role of hospitals, health plans, and geography as determinates of racial disparities, but little is known about interventions to improve cultural competency and track clinical progress with individual physicians.
“Our study should remind all of us that cultural competency training is important, but it should be understood as only one arrow in the quiver of primary care.” Sequist concludes: “We need a team approach—that purposefully and effectively coordinates care delivery among physicians, nurses, physician assistants, nutritionists and pharmacists—to bridge the quality gap and improve care for minority patients.”
Diabetes has been rising steadily in the United States since 1980. Recent data from the U.S. Centers for Disease Control and Prevent (CDC) shows the number of diagnoses has tripled since then, jumping from 5.6 million to 17.9 million in 2007. An additional 5.7 million are estimated to have undiagnosed diabetes. By 2034, the total number of individuals with diabetes is projected reach 44.1 million according to the CDC.
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