racial/ethnic disparities in quality of ambulatory care for chronic physical health conditions: t he...

Racial/Ethnic Disparities in Quality of Racial/Ethnic Disparities in Quality of Ambulatory Care for Chronic Physical Ambulatory Care for Chronic Physical Health Conditions: Health Conditions: TThe effects of he effects of physician and care setting characteristicsphysician and care setting characteristics

Sponsored by The Robert Wood Johnson Sponsored by The Robert Wood Johnson Foundation, New Connections ProgramFoundation, New Connections ProgramAcademy Health Conference June 2008Academy Health Conference June 2008

Rhonda BeLue PhDRhonda BeLue PhDThe Pennsylvania State UniversityThe Pennsylvania State University

OverviewOverview

BackgroundBackground Rationale Rationale Study ObjectivesStudy Objectives MethodsMethods

DataData MeasuresMeasures AnalysisAnalysis

Results Results Conclusions and ImplicationsConclusions and Implications

BackgroundBackground

Background : Disparities Background : Disparities in Health Care Qualityin Health Care Quality

Racial/Ethnic inequities in exist in Racial/Ethnic inequities in exist in multiple domains of quantity and quality multiple domains of quantity and quality of care: safety, timeliness, effectiveness, of care: safety, timeliness, effectiveness, efficiency, equity, and patient-efficiency, equity, and patient-centeredness centeredness

(Aaron 2003, Aaron 2003, Kirby 2006, IOM, (Aaron 2003, Aaron 2003, Kirby 2006, IOM, Mayberry 2006, Ma 2005, Weisfeld 2005). Mayberry 2006, Ma 2005, Weisfeld 2005).


Disparities exist across a wide variety of Disparities exist across a wide variety of treatments for multiple conditions: treatments for multiple conditions: including treatment for CVD, Heart failure including treatment for CVD, Heart failure and diabetes (IOM, Unequal Treatment). and diabetes (IOM, Unequal Treatment).

It is believed that poor quality of care for It is believed that poor quality of care for ethnic minorities is linked to poor health ethnic minorities is linked to poor health care outcomes. (Lavizzo-Mourey 2005)care outcomes. (Lavizzo-Mourey 2005)


In fact, it has been shown that In fact, it has been shown that improvements in quality of care for all US improvements in quality of care for all US consumers are necessary (Asch 2006). consumers are necessary (Asch 2006).

Wide variation also exists in racial Wide variation also exists in racial disparities across geographic lines and disparities across geographic lines and care settings care settings

(Baiker 2005, Baiker 2004, Wennberg 2006) Bach (Baiker 2005, Baiker 2004, Wennberg 2006) Bach 2004, 2005). 2004, 2005).


Despite the documented existence of Despite the documented existence of inequities in healthcare quality, more inequities in healthcare quality, more work is needed to understand and test work is needed to understand and test strategies to improve the quality of strategies to improve the quality of healthcare for ethnic minority populations healthcare for ethnic minority populations (Beach 2006). (Beach 2006).


African Americans are more likely to see health care African Americans are more likely to see health care providers in facilities with inadequate recourses and by providers in facilities with inadequate recourses and by providers with lesser credentials than facilities where providers with lesser credentials than facilities where whites receive care (Epstein 2004, Bach 2004). whites receive care (Epstein 2004, Bach 2004).

African Americans are also likely to have poorer African Americans are also likely to have poorer continuity of care largely due to lack of regular site of continuity of care largely due to lack of regular site of care. care.

African Americans are more likely to African Americans are more likely to be seen in hospital clinics and be seen in hospital clinics and community health centers where the community health centers where the chances of seeing the same provider chances of seeing the same provider across visits are low (Doescher across visits are low (Doescher 2001). 2001).


Peter Bach et al (2004) found that elderly Peter Bach et al (2004) found that elderly Blacks and Whites are treated at racially Blacks and Whites are treated at racially homogeneous facilities that are either homogeneous facilities that are either largely White or African American.largely White or African American.

BackgroundBackground Elderly blacks receive care at facilities which:Elderly blacks receive care at facilities which:

1) provided more charity care1) provided more charity care 2) had higher percentage of revenue from 2) had higher percentage of revenue from

Medicaid Medicaid 3) were more likely to practice in a low-income 3) were more likely to practice in a low-income

neighborhood and neighborhood and 4) were less likely to be board certified in their 4) were less likely to be board certified in their

primary specialty. primary specialty. 5) Physicians treating mostly white patients were 5) Physicians treating mostly white patients were

more likely to indicate that they could confidently more likely to indicate that they could confidently provide quality care and access to referrals, provide quality care and access to referrals, specialty care, and ancillary servicesspecialty care, and ancillary services

RationaleRationale

Understanding the characteristics of Understanding the characteristics of health care facilities can inform health care facilities can inform interventions and policy making related to interventions and policy making related to consumer access to care and choice of consumer access to care and choice of health care setting, resource health care setting, resource management and allocation in settings management and allocation in settings that treat racial/ethnic minorities receive that treat racial/ethnic minorities receive care care

ContributionContribution

This study adds to the literature by This study adds to the literature by investigating the relationship between investigating the relationship between healthcare setting context and quality of healthcare setting context and quality of care received for chronic conditions in care received for chronic conditions in adults ages 18 and older.adults ages 18 and older.

Diabetes will be used as an illustration for Diabetes will be used as an illustration for this presentationthis presentation

ObjectivesObjectives

Assess:Assess: 1) racial/ethnic differences in the 1) racial/ethnic differences in the

characteristics of the facilities where characteristics of the facilities where racial and ethnic minorities receive racial and ethnic minorities receive carecare

2)2) The relationship between quality of The relationship between quality of care for diabetes and characteristics care for diabetes and characteristics of the care settingof the care setting

Conceptual Framework: Conceptual Framework: The Chronic Care ModelThe Chronic Care Model

Summarizes the basic elements for improving Summarizes the basic elements for improving care in health systems at the community, care in health systems at the community, organization, practice and patient levels. organization, practice and patient levels.

Community characteristicsCommunity characteristics: resources and policies: resources and policies Health system characteristicsHealth system characteristics: clinical information : clinical information

systems, design and delivery systemsystems, design and delivery system Provider characteristicsProvider characteristics: prepared and proactive: prepared and proactive Patient characteristicsPatient characteristics: activated patient: activated patient

MethodsMethods

Data and SampleData and Sample

The 2005 National Ambulatory Medical Care Survey The 2005 National Ambulatory Medical Care Survey (NAMCS) were used for this investigation. (NAMCS) were used for this investigation.

NAMCS uses a multistage stratified probability sample of NAMCS uses a multistage stratified probability sample of patient visits in ambulatory care settings to enable patient visits in ambulatory care settings to enable nationally nationally

NAMCS is designed obtain objective information about NAMCS is designed obtain objective information about ambulatory medical care services in the United States ambulatory medical care services in the United States

Whites, Blacks, and Hispanics aged 40 and older with Whites, Blacks, and Hispanics aged 40 and older with DiabetesDiabetes Several other ACS conditions were exploredSeveral other ACS conditions were explored

MeasurementMeasurement

Patients with conditions (diabetes) of Patients with conditions (diabetes) of interest were identified via ICD9 code (as interest were identified via ICD9 code (as indicated by the NAMCS diagnosis indicated by the NAMCS diagnosis variable) and confirmed by physician variable) and confirmed by physician report. report.

First, second and third diagnoses were First, second and third diagnoses were included included Checked against physician reportChecked against physician report

Measures: Facility and Measures: Facility and Physician CharacteristicsPhysician Characteristics

FacilityFacility Solo or group practiceSolo or group practice OwnershipOwnership Lab Testing availableLab Testing available Difficulty with referralsDifficulty with referrals EMREMR % of revenue % of revenue Claims submitted Claims submitted

electronicallyelectronically

Physician:Physician: Employment statusEmployment status Does email consultsDoes email consults Telephone consultsTelephone consults Hospital visitsHospital visits Time spent with Time spent with

patientpatient

Measures: Patient Measures: Patient CharacteristicsCharacteristics

Demographics: age, gender, insurance Demographics: age, gender, insurance statusstatus

Comorbid illnesses: bmi, total number of Comorbid illnesses: bmi, total number of chronic conditions, number of medicationschronic conditions, number of medications

Number of visits in the past 12 monthsNumber of visits in the past 12 months Number of MedicationsNumber of Medications

Measures: Dependent Measures: Dependent VariablesVariables

Quality measure(s) were derived based Quality measure(s) were derived based on measures from:on measures from: The National Quality Measures Clearing The National Quality Measures Clearing

HouseHouse Selected measures relevant to ambulatory Selected measures relevant to ambulatory

care settingscare settings

Quality indicators were calculated as the Quality indicators were calculated as the percentage of visits in which the patient percentage of visits in which the patient received appropriate quality of care received appropriate quality of care divided by the total number of visits. divided by the total number of visits.

Diabetes Quality Diabetes Quality OutcomeOutcome

Ambulatory care management of Ambulatory care management of diabetes measurediabetes measure

DiabetesDiabetes Process:Process:

% of patients who received a HA1c test% of patients who received a HA1c test

*Should be taken every 3 months, especially in those *Should be taken every 3 months, especially in those with poor glycemic controlwith poor glycemic control

Analytic StrategyAnalytic Strategy

Analytic Strategy: Aim 1Analytic Strategy: Aim 1

Chi-square tests using Stata survey Chi-square tests using Stata survey procedures were employed to examine procedures were employed to examine the relationship between race/ethnicity the relationship between race/ethnicity and care setting characteristicsand care setting characteristics

Analytic Strategy: Aim 2Analytic Strategy: Aim 2

Logistic regression analyses were employed to Logistic regression analyses were employed to examine the relationship between race, examine the relationship between race, provider and facility characteristics and quality provider and facility characteristics and quality indicator controlling for patient demographic indicator controlling for patient demographic and health status indicators and health status indicators Sample/design weights were incorporated Sample/design weights were incorporated GEE for parameter estimationGEE for parameter estimation Assessed moderation-within race/ethnicity modelsAssessed moderation-within race/ethnicity models Bonferroni adjustment for multiple comparisonsBonferroni adjustment for multiple comparisons Modeled the probability of receiving HGBAModeled the probability of receiving HGBA

ResultsResults

Sample CharacteristicsSample Characteristics

Sample represents a total of 15858 Sample represents a total of 15858 patient encounters among those over 40, patient encounters among those over 40,

% of patient encounters among those % of patient encounters among those with diabetes (weighted):with diabetes (weighted):

N=3078 diabeticsN=3078 diabetics White: 11.5%White: 11.5% Black: 18.9%Black: 18.9% Latino/a: 16.8%Latino/a: 16.8%

Race and Outcome Race and Outcome MeasuresMeasures

DiabetesDiabetes

Among those who have diabetes, Among those who have diabetes, approximately at any encounter:approximately at any encounter: 13.9% of whites receive an HA1c screening13.9% of whites receive an HA1c screening

7.4% of blacks receive an HA1c screening7.4% of blacks receive an HA1c screening

8.4% of Latino/as receive an HA1c 8.4% of Latino/as receive an HA1c screeningscreening

Significant at P<0.001 Significant at P<0.001

Results Aim 1Results Aim 1 White (%) Black (%) Latino (%) Does the physician do email consults? (yes)

59.1

60.0

51.0

Difficulty Referring Private Patients

14.9 13.6 13.6

Difficulty Referring Uninsured Patients

48.0 49.0 48.0

Difficulty Referring Medicare Patients

12.8 12.3 22.3

Difficulty referring Medicaid patients

50.2 48.2 52.6

> 50% revenue from Medicaid 2.1 6.6 14.0 >50 %revenue from Medicare 25.0 19.9 20.0 >50 %revenue from Managed Care Contracts

40.5 45.6 52.4

Solo Practice 39.0 44.8 40.9 Submit Electronic claims 86.2 86.4 87.5 Has EMR system 26.6 22.7 26.3 Lab Testing Performed in Office 43.2 43.3 43.2

Results: Aim 2-WhitesResults: Aim 2-Whites

More that 50% or revenue from More that 50% or revenue from Medicare-Medicare- OR = OR = 0.24 ( 0.1, 0.5)

Difficulty Referring to Medicaid –Difficulty Referring to Medicaid – OR=0.35 ( 0.2, 0.7)OR=0.35 ( 0.2, 0.7)

Results: Aim 2-BlacksResults: Aim 2-Blacks

Seen in a solo practiceSeen in a solo practice : : OR = 1.8(1.7,2.1)OR = 1.8(1.7,2.1)

More that 50% or revenue from Medicare-More that 50% or revenue from Medicare- : : OR = 0.4(0.1,0.7)OR = 0.4(0.1,0.7)

On Site Lab:On Site Lab: OR= 5.7(1.5,7.2)OR= 5.7(1.5,7.2)

Results: Aim 2-LatinosResults: Aim 2-Latinos

Seen in a solo practiceSeen in a solo practice : : OR = 2.1(1.6,2.7)OR = 2.1(1.6,2.7)

On Site Lab:On Site Lab: OR= 1.5(1.5,7.2)OR= 1.5(1.5,7.2)

LimitationsLimitations

Cross-sectional dataCross-sectional data Lack of financial data to accurately asses level Lack of financial data to accurately asses level

of resourcesof resources Need of composite score or better Need of composite score or better

interpretation of what facility characteristics interpretation of what facility characteristics meanmean

Patient preferences for care settingPatient preferences for care setting Combine several years to increase N for Combine several years to increase N for

minority groups and to allow for more minority groups and to allow for more comparisonscomparisons

ConclusionsConclusions

Future health services and quality Future health services and quality initiatives may benefit from focusing on initiatives may benefit from focusing on improving resources in care settings in improving resources in care settings in order to improve quality and treatment of order to improve quality and treatment of chronic conditions in racial and ethnic chronic conditions in racial and ethnic minoritiesminorities

AcknowledgementsAcknowledgements

The Robert Wood Johnson Foundation, The Robert Wood Johnson Foundation, New Connections ProgramNew Connections Program

Dr. Debra J. PerezDr. Debra J. Perez Dr. Margarita AlegriaDr. Margarita Alegria Junior Investigator Forum ColleaguesJunior Investigator Forum Colleagues

racial/ethnic disparities in quality of ambulatory care for chronic physical health conditions: t he...

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