American Diabetes Association Conference Highlights: Racial Disparities in Diabetes Care

Healthcare providers' implicit bias regarding race directly corresponds with worse medical outcomes

With Bryan Batch MD

“It doesn’t take a lot to look at our charts and understand that we need to be more aware of our role in discrepancies in glucose control by race. But, as healthcare providers, we have to buy into it and decide that it’s important.”

 

As the Coronavirus has ravaged millions of lives in the United States, further evidence has emerged that BIPOC patients don’t get the same benefit from the healthcare system as white people. A report from the Centers for Medicare and Medicaid Services (CMS) found that race and income were primary determinants of Covid-19 outcomes, and several other recent studies have found similar results.

Racial disparities continue to have an impact among patients with diabetes

While these studies were being published, another report found that racial disparities continue to have an impact among patients with diabetes, too. Duke medical student and researcher Hadley Reid, BA and a team including Bryan Batch, MD, MHS, an endocrinology professor and co-director of community engagement and dissemination at the Reach Equity Center, presented their findings at the virtual American Diabetes Association conference in June.

The researchers’ work, due to be published by the end of the year, looked at a group of patients at 34 primary care practices – both non-Hispanic black and non-Hispanic white patients. According to the Centers for Disease Control and Prevention, black patients are more likely to be diabetic and have worse medical outcomes.

The Association between glycemic control and race

The group looked at the association between glycemic control and race, using A1c levels, patient race, and scores from a patient survey to determine which areas of patient/provider interaction were potentially different. They gave 106 non-Hispanic white and 115 non-Hispanic black patients the Interpersonal Processes of Care survey, which includes seven subdomains:

  • Whether providers hurried communication with patients
  • Whether providers elicited concerns and responded
  • Whether providers explained results and medications
  • Whether providers offered patient-centered decision making
  • Whether providers were compassionate and respectful
  • If patients felt discriminated against 
  • Whether patients experienced disrespectful office staff

They used the clinical information they gained from health records to look at glucose control compared to the answers the patients provided on the surveys.

A1c was 0.64% lower among black patients who said that their providers explained results and medications compared to those who did not

In two of the domains, they found statistically significant differences in the two groups – the A1c was 0.45% lower among non-Hispanic black patients who did not report hurried communication compared to those who did. A1c was 0.64% lower among black patients who said that their providers explained results and medications compared to those who did not.

Reid says that as a medical student working at the Reach Center on how to identify, characterize, and address issues of health disparities, she had clinical patients where with earlier intervention, there could have been better outcomes. It helped inspire this work, as well as other work currently being written up that looks at how provider's implicit bias regarding race directly corresponds to medical outcomes.

One problem Reid sees is how we train providers about implicit bias. “What we are doing now isn’t action oriented. We need toolkits that help them apply what they have learned. I think that in this work, we can find ways to intervene regarding hurried communication and medication explanations. It can be hard to actualize how we aren’t doing well by these patients, but these domains provide us with a way to create action items.”

How to translate the recognition of bias and racism into actionable change

The crux for providers, healthcare organizations, and health systems is how to translate the recognition of bias and racism into actionable change, says Batch. “Sometimes, as an endocrinologist, I don’t know who the patient is. The medical record doesn’t capture the patient experience as a person – from race and culture perspectives.”

Doctors tend to focus on every individual, says Batch, and that informs how they communicate. But patients benefit when healthcare providers communicate with them as consistently. She points to work in cardiology, where there are also large racial disparities in outcomes. “Studies have shown it could be how we talk to people about procedures – are we giving the same information in lay language, and giving the same options regardless of age, sex, or race?”

 “We need to identify the parts of the conversation where we are failing patients,” says Batch. Standardizing language and approach by using videos could be a way to help ensure that happens. Then providers can enter the conversation after patients see the videos with their options to discuss specifics for that patient that may inform care going forward.

Training needs to include what are known to be essential elements of ensuring that all patients have the best possible outcomes

For now, training needs to include what are known to be essential elements of ensuring that all patients have the best possible outcomes, such as making eye contact and not rushing patients through their medical consultations. “First, know you can do better. Then make use of the resources that are already available,” says Batch.

Reid says it can be hard to get providers to admit their role in systemic racism, implicit bias, and healthcare disparities. “We often don’t even ask providers if they acknowledge that structure and systems have an unequal impact on patients,” she says.

“The healthcare providers who are often willing to admit these things are the ones engaging in the work and thinking about making necessary changes. The difficulty is designing interventions that are tailored to HCPs who need it more, who are not engaged, and who are not participating in these studies.”

A vital point is ensuring that the institution as a whole values patient equality

A vital point is ensuring that the institution as a whole values this work, which can be expensive or time consuming, says Reid. “Do they value this enough to put incentives in place to make participation in these efforts attractive?”

For now, physicians can easily make an effort to listen more to patients as individuals. “Don’t hurry through your communications and education. Listen to their unique needs, which may be influenced by race. Be efficient, but purposeful in your explanations.”

Batch says that most providers assume their skills are adequate. “But every single person can benefit from input from communications experts who can observe providers and give them feedback on ways to improve communications.

“There is a lot in the literature about the right choice of medication, but the cost of them can have a huge impact,” she explains. The standard is to offer the cheapest drug first. But better communication would help a provider determine if one is better than another – for instance, that a patient might not be able to take something three times a day or has a fear of needles. “We need to move to choosing the best medication first for an individual patient. Don’t make assumptions about what they can or cannot manage.”

Physicians also have biases that are baked into how they talk about treatment options. “We assume we are doing the best for our patients,” Batch says. It can be empowering to look at the data and see if you can find areas to improve.

“It doesn’t take a lot to look at our charts and understand that we need to be more aware of our role in discrepancies in glucose control by race. But, as healthcare providers, we have to buy into it and decide that it’s important.” 

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