Health Care After You Leave the Doctor’s Office
Community-based outreach to address diabetic health care disparities offers broader lessons.
Federal officials were concerned after the 2006 National Healthcare Disparities Report confirmed growing disparities in health care among older Hispanics nationwide, in particular for diabetes.
It's no secret that diabetes — a chronic condition that without proper care, particularly in older people, can result in blindness, amputation and death — disproportionately affects Hispanic populations. The Centers for Disease Control and Prevention determined in 2005 that 10.2 percent of U.S. Hispanics would be diagnosed with diabetes, compared with 6.9 percent for (non-Hispanic) whites. Hispanics were 50 percent more likely to die from the disease than were whites.
Meanwhile, diabetes is a burgeoning health threat for all Americans — the CDC announced today that the incidence of type 2 diabetes has almost doubled since 1997.
But the new report found disparities not in incidence but in care.
"Health disparity can be difficult to define, and, ultimately, the reasons may not always be known, but its effect — lack of proper or appropriate care based upon standards — is where we focus for change," said Dr. Ernest Moy, the medical officer in charge of data analysis for the Agency for Healthcare Research and Quality (AHRQ) Center for Quality Improvement and Patient Safety.
The Disparities report, compiled since 2005 from millions of anonymous patient records from public and private health sources, compares these findings to a standard of 150 quality-care measures. Moy said when the standards of care are not met — "if children are not getting vision exams, or women are not being screened for mammograms, or people with chronic disease are not getting tests or taking their medicine properly" — then that population is reported to have a health disparity.
The results echo a meta-analysis published in February's Diabetes Care journal. Lead author Julienne Kirk, associate professor of family and community medicine at the Wake Forest University School of Medicine, also was struck by the care disparity.
"We were not surprised by these findings since ethnic minorities in the U.S. are disproportionately affected by diabetes, and we found a similar trend in the African-American population with diabetes a year ago," she said in a press release announcing the study. "What did surprise us were the results of our analysis of subgroups of patients with managed care and non-managed care insurance. The largest difference for A1C (a blood test that identifies difficulty controlling their blood sugar) was among non-managed care insurance groups.
"A high percentage of Hispanics in this country have low incomes, no health insurance and limited access to health care. The Hispanic population has a high prevalence of diabetes and higher A1C than non-Hispanic whites. This further elucidates the health disparities that characterize the Hispanic population."
To address the persistent health disparities among elderly Hispanics, particularly in diabetes, the Department of Health and Human Services authorized a new federal collaborative called the Learning Network.
AHRQ spokeswoman Ellen Crown said the program, launched last year, includes technical assistance, education and outreach support from five federal groups: AHRQ, CDC, Agency on Aging, Center for Medicare and Medicaid Services and the Health Resources and Services Administration. The goal is to "create a unique program that cuts across traditional organization boundaries at the local level" to improve health care delivery for elderly Hispanics.
Moy said that while prevention is the best way to achieve better outcomes, insurers frequently won't invest in it because the payoff often comes after individuals leave specific insurance companies or migrate to public health plans. But while people may change insurers or go to Medicare, they're likely to remain in the same community, which makes community partnering a great way to close the gap in care.
The collaboration targeted several regions with large Hispanic populations: New York City, Chicago, Miami, Houston, San Antonio and the Lower Rio Grande, San Diego and Los Angeles. "Each of our eight target communities is a unique cultural scenario — what works in New York may fail in Miami," Crown said. The participants could select their area of disease focus but most chose diabetes care.
Earlier this month, San Antonio Network participant Carol Zernial, director of Texas' Bexar Area Agency on Aging (local Area Agencies on Aging were the initial points of contact to introduce the Learning Network program), presented her challenges and successes from the program at AHRQ's annual meeting.
"As of October 2007, the National Association of County and City Health Officials reported San Antonio as having the second-highest diabetes-related death rate — following New Orleans — in the nation. Here in our community, we estimate the rate of diabetes in older Hispanics may be as high as 59 percent."
Zernial said that their biggest success was through the composition of their outreach and awareness team — "we've never worked with physicians before" — and emphasized the importance of "clinical wrap-around services."
"Patients spend, maybe if they're lucky, 10-15 minutes with their physician and the rest of their life in the community, so we have to reinforce the messages and information they hear in the doctor's office everywhere else."
After presenting the compelling federal data on health disparities, Zernial was able to enlist the support of local physicians, churches, community centers and other government social service agencies. (In August, Ryan Blitstein looked at another care initiative, Poder es Salud, that capitalized on social ties.)
Zernial stressed the value of engaging the entire public and private community, something she agrees would not have been possible without the federally provided data.
Meanwhile, through the Learning Network process, Zernial uncovered a variety of reasons why Hispanics were not receiving, or accessing, care for diabetes.
"Some are just resigned, saying it is inevitable as 'everyone in their family has it,'" she said. "This age group also has more difficulty getting transportation to care. Once they get to the office, they are also generally less willing to question the doctor, particularly if there is a cultural or language barrier, to ask for more explanation."
She also described how individuals are likely to have one doctor until they're 65, but once older than 65, they "transition to Medicare and may see a variety of doctors in the system." When the paper trail of care is more difficult to follow, it is harder to ensure proper health needs are being met.
Now, after a little more than a year, Zernial believes this model holds great promise for reducing the health disparity of diabetes in older Hispanics. She hopes to make this program a benchmark to use for other diseases that affect elderly populations in her community.
Moy said while the program lacks "real numbers now" about measureable outcomes, what we can expect is that, first, the processes of care delivery will change, and we will see in the short term a change in attitudes among doctors and also their patients concerning the standards of care for this disease, such as better monitoring of A1C test, more frequent eye/retina screens and more foot exams.
After changes in health-delivery processes, he expects to see more changes with the patient in self-care. For example, people who might have had difficulty keeping the message about eating right and watching sweets will now be reinforced by community-based messages, so they will pay more attention to daily finger sticks, better food choices, exercising.
Ultimately, he believes, we will see fewer diabetes-related deaths, amputations and hospitalizations.
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