Objective

This study examines the association between physician gender and diabetes quality of care.

Research design and methods

We examined the association between the gender of primary care physicians (n = 1,686) and the quality of diabetes care they provided to their patients participating in the Translating Research Into Action for Diabetes (TRIAD) study. Main outcome measures were diabetes processes of care including receipt of dilated retinal exams, urine microalbumin/protein testing, foot exams, lipid and HbA(1c) (A1C) testing, recommendation to take aspirin, and influenza vaccination over 1 year. Intermediate outcomes included blood pressure, A1C, LDL levels, and patient satisfaction. Hierarchical regression models accounted for clustering within provider groups and health plans and adjusted for patient age, gender, race, income, education, diabetes treatment and duration, and health status, along with physician age, years of practice, and specialty.

Results

Compared with male physicians (n = 1,213), female physicians (n = 473) were younger, had more recently completed training, and were more often internists. Patients of female physicians (n = 4,585) were more often women and younger than patients of male physicians (n = 1,783). In adjusted analyses, patients of female physicians were slightly more likely to receive lipid measurements (predicted probability 1.09 [95% CI 1.02-1.15]) and A1C measurements (1.02 [1.00-1.05]) and were slightly more likely to have an LDL <130 mg/dl (1.05 [1.00-1.10]).

Conclusions

Patients of female physicians received similar quality of care compared with patients of male physicians.

Objective

To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.

Study design

Cross-sectional analysis.

Methods

Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.

Results

Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.

Conclusions

Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.

Objectives

We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care.

Methods

Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos.

Results

Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care.

Conclusions

Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.

Abstract Background To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD. Methods Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration. Results A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell’s c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved. Conclusions The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.

Objective

We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care.

Research design and methods

Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry.

Results

Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes.

Conclusions

For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Background

Although disease management programs are widely implemented, little is known about their effectiveness.

Objective

To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels.

Design

Cross-sectional study.

Setting

Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%).

Patients

8661 adults with diabetes who completed a survey (2000-2001) and had medical record data.

Measurements

Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use.

Results

Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management.

Limitations

Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups.

Conclusions

Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

Background

Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.

Objective

To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.

Design

Case-control study.

Subjects

A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.

Measures

Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c > or =8.0%, SBP > or =140 mmHg, LDL cholesterol > or =130 mg/dL) and controls were patients with good control of all 3 (HbA1c <8.0%, SBP <140 mmHg, LDL cholesterol <130 mg/dL). In multivariate analyses, we determined whether each of several potentially mutable risk factors, including depression, poor adherence to medications, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status.

Results

Among blacks but not whites, in multivariate analyses depression (odds ratio: 2.28; 95% confidence interval: 1.09-4.75) and having missed medication doses (odds ratio: 1.96; 95% confidence interval: 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites.

Conclusions

Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These 2 risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.