Assessing Diabetes Care Disparities with Ambulatory Care Quality Measures

Diabetes is the seventh leading cause of death in the United States and a major contributor to cardiovascular disease (CVD), including heart disease and stroke (Centers for Disease Control and Prevention 2011). Diabetes management involves a delicate balance between lifestyle management and pharmacological treatment of major risk factors. To reduce the risk of debilitating health complications (such as kidney failure, nontraumatic lower limb amputations, and blindness) and CVD events, optimal control of risk factors is crucial for patients with diabetes (Centers for Disease Control and Prevention 2011; Egede et al. 2011; Minnesota Community Measurement 2011; American Diabetes Association [ADA], 2012). Optimally managed diabetes involves achieving recommended goals for Hemoglobin A1C (HbA1C), blood pressure, LDL cholesterol, tobacco, and aspirin use (Minnesota Community Measurement 2011). We combine these risk factors into a composite measure to evaluate overall diabetes management of CVD risk factors; this measure will be referred to as optimal diabetes care (ODC) in this paper (Minnesota Community Measurement 2011). The ODC measure, along with other quality measures, is reported annually by health care organizations in Minnesota to Minnesota Community Measurement (MNCM), a nonprofit organization that publicly reports these data for quality improvement efforts. MNCM measures were developed by a committee that includes health care providers and health plans and are informed by national standards. The ODC measure is endorsed by the National Quality Forum. MNCM has recently begun to report disparities through its Health Care Disparities Report. However, racial/ethnic ODC disparities are not currently reported (Minnesota Community Measurement 2011). Identifying and addressing disparities in ODC are important due to evidence of racial/ethnic disparities in diabetes prevalence, complications, diabetes-related hospital admissions, and readmissions in minority populations (Lanting et al. 2005; Russo, Andrews, and Coffey 2006; Jiang, Russo, and Barrett 2009; Agency for Healthcare Research and Quality 2012; Johnson, Ghildayal, and Wheeler 2012). With the projected diabetes burden increase in the United States in part due to “increasing numbers of members of higher risk minority groups in the population,” continued evaluation and documentation of disparities is still needed today (Boyle et al. 2010). Although disparities have gained national attention over the past decade, documentation is still relevant particularly as an example for health systems that are not currently evaluating disparities using their quality metrics (Trivedi et al. 2006). Studies have documented racial/ethnic disparities in individual ODC risk factors (Campbell et al. 2012). However, few studies have used a composite measure of risk factors to evaluate disparities in overall management. Without a composite measure, we cannot assess whether a patient who has met the HbA1C goal has also met the other goals. It is therefore unclear whether a particular patient has optimally managed diabetes. The few studies that have used composite measures were conducted in specific populations, or used different criteria, and included limited racial and ethnic groups (Jackson, Edelman, and Weinberger 2006; Selby et al. 2007; Duru et al. 2009; Egede et al. 2011). Our study expands on these previous studies by including more racial/ethnic groups in a broader patient population and including additional risk factors to assess overall diabetes management.