Do Quality Improvement Initiatives for Diabetes Care Address Social Inequities? Secondary Analysis of a Systematic Review

Lu JB, Danko KJ, Elfassy MD, Welch V, Grimshaw JM, Ivers NM
Source: BMJ Open
Publication Year: 2018
Patient Need Addressed: Chronic Conditions
Population Focus: Vulnerable/disadvantaged
Intervention Type: Staff design and care management
Study Design: Review
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/29444781
Abstract

BACKGROUND:
Socially disadvantaged populations carry a disproportionate burden of diabetes-related morbidity and mortality. There is an emerging interest in quality improvement (QI) strategies in the care of patients with diabetes, however, the effect of these interventions on disadvantaged groups remains unclear.

OBJECTIVE:
This is a secondary analysis of a systematic review that seeks to examine the extent of equity considerations in diabetes QI studies, specifically quantifying the proportion of studies that target interventions toward disadvantaged populations and conduct analyses on the impact of interventions on disadvantaged groups.

RESEARCH DESIGN AND

METHODS:
Studies were identified using Medline, HealthStar and the Cochrane Effective Practice and Organization of Care database. Randomized controlled trials assessing 12 QI strategies targeting health systems, healthcare professionals and/or patients for the management of adult outpatients with diabetes were eligible. The place of residence, race/ethnicity/culture/language, occupational status, gender/sexual identity, religious affiliations, education level, socioeconomic status, social capital, plus age, disability, sexual preferences and relationships (PROGRESS-Plus) framework was used to identify trials that focused on disadvantaged patient populations, to examine the types of equity-relevant factors that are being considered and to explore temporal trends in equity-relevant diabetes QI trials.

RESULTS:
Of the 278 trials that met the inclusion criteria, 95 trials had equity-relevant considerations. These include 64 targeted trials that focused on a disadvantaged population with the aim to improve the health status of that population and 31 general trials that undertook subgroup analyses to assess the extent to which their interventions may have had differential impacts on disadvantaged subgroups. Trials predominantly focused on race/ethnicity, socioeconomic status and place of residence as potential factors for disadvantage in patients receiving diabetes care.

CONCLUSIONS:
Less than one-third of diabetes QI trials included equity-relevant considerations, limiting the relevance and applicability of their data to disadvantaged populations. There is a need for better data collection, reporting, analysis and interventions on the social determinants of health that may influence the health outcomes of patients with diabetes.

Insights Results

Overview of article

  • This study used the place of residence, race/ethnicity/culture/language, occupational status, gender/sexual identity, religious affiliations, education level, socioeconomic status, social capital, plus age, disability, sexual preferences and relationships (PROGRESS-Plus) framework to consider the range of factors that may increase the risk for a population subgroup to be disadvantaged

Methods of article

  • Studies were identified using Medline, HealthStar and the Cochrane Effective Practice and Organization of Care database. Randomized controlled trials assessing 12 quality improvement (QI) strategies targeting health systems, healthcare professionals and/or patients for the management of adult outpatients with diabetes were included in the analysis
  • The place of residence, race/ethnicity/culture/language, occupational status, gender/sexual identity, religious affiliations, education level, socioeconomic status, social capital, plus age, disability, sexual preferences and relationships (PROGRESS-Plus) framework was used to identify trials that focused on disadvantaged patient populations, to examine the types of equity-relevant factors that are being considered and to explore temporal trends in equity-relevant diabetes QI trials

Results

  • The initial literature search identified a total of 7248 citations; review of 2691 full text articles resulted in a final sample of 309 reports, representing 272 unique trials
  • Of these trials, 95 trials (35%) were identified as equity-related (targeted to a specific disadvantaged population and general)
  • Overall, age and gender/sex were the most frequently documented PROGRESS-Plus factors in both equity-relevant studies and non-equity studies. In comparison, race/ethnicity/culture/language, socioeconomic status, education, social capital, occupation and place of residence (as defined by PROGRESS-Plus) appeared significantly more frequently in equity-relevant trials than in non-equity trials
  • 53% of targeted trials focused on race/ethnicity/culture/language, 30% on residence, and 28% on socioeconomic status
  • 22 trials looked at 2 or more PROGRESS-Plus features, which is important because many disadvantaged populations because the risk for disparities increases with more PROGRESS-Plus factors
  • Prior to 2007 (compared to 2007-2014), there was a growth in equity-related trials

Key takeaways/implications

  • Quality improvement (QI) strategies designed for the general public may not be applicable to disadvantaged populations, calling attention to a need for more data collection, reporting and analysis on social determinants of health
  • Interventions tailored toward socially disadvantaged populations show promising results in reducing health disparities in diabetes care. Additionally, culturally sensitive strategies can help strengthen connections between patients and healthcare organizations
  • Limitations to the study include exclusion of non-English articles, focus on primary publications (and not subsequent studies), inability to evaluate all issues that may affect disadvantaged populations
NEW SEARCH