Racial differences in outcome of treatment

By KEVIN SACK
Published: June 10, 2008

As researchers ponder growing evidence that blacks have worse outcomes than whites in the treatment of chronic disease, they often theorize that members of minorities suffer disproportionately from poor access to quality care. Now a new study of diabetes patients has found stark racial disparities even among patients treated by the same doctors.
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The lead author of the study said in an interview that he attributed the differences less to overt racism than to a systemic failure to tailor treatments to patients’ cultural norms. The problem, said the author, Dr. Thomas D. Sequist, an assistant professor of health care policy at Harvard Medical School, may be that physicians do not discriminate in the way they counsel patients.

“It isn’t that providers are doing different things for different patients,” Dr. Sequist said. “It’s that we’re doing the same thing for every patient and not accounting for individual needs. Our one-size-fits-all approach may leave minority patients with needs that aren’t being met.”

For instance, he said, counseling black or Latino patients with diabetes to lower their carbohydrate intake by cutting rice from their diets may not be a realistic strategy if rice is a family staple.

“We may be listing fruits and vegetables that are part of one person’s culture but not another,” Dr. Sequist said. “We’re not really giving them information they can use.”

In the study, which was published Monday in The Archives of Internal Medicine, Dr. Sequist and his colleagues examined electronic medical records of 6,814 patients with diabetes. All were treated from 2005 to 2007 by at least one of 90 primary care physicians with Harvard Vanguard Medical Associates, which has 14 walk-in health clinics in eastern Massachusetts. Each doctor treated at least five white patients and five black ones.

The researchers looked at three standard measures of effective diabetes control: blood pressure, LDL cholesterol levels and hemoglobin A1C, which reflects blood sugar. Though similar proportions of black and white patients took each test, fewer black patients adequately controlled their levels on all three measures. The glucose test found, for example, that 71 percent of white patients and 63 percent of black ones were adequately controlling their blood sugar levels.

Socioeconomic factors like income or insurance status explained 13 percent to 38 percent of the racial differences, the authors calculated. But they found much larger racial disparities — from 66 percent to 75 percent — in patients who were treated by the same doctor. Adjusting for clinical differences among patients did not change the findings.

“Racial differences in outcomes were not related to black patients differentially receiving care from physicians who provide a lower quality of care, but rather that black patients experienced less ideal or even adequate outcomes than white patients within the same physician panel,” the study concluded.

To attack such disparities, the authors recommended that doctors and other members of the health care system learn more about minority communities and that patients receive better education about diabetes and how and why it must be controlled.

“Our data suggest that the problem of racial disparities is not characterized by only a few physicians providing markedly unequal care,” the authors wrote, “but that such differences in care are spread across the entire system, requiring the implementation of systemwide solutions.”