A Black-White Diabetes Divide

Black patients with diabetes do worse than white patients — even when they're getting treatment from the same doctor. That's the message of a new study published this week in the journal Archives of Internal Medicine. It's not the first paper to document health disparities between black and white diabetics, but it breaks new ground: By looking at the outcome discrepancy among a group of patients with access to the same health facilities — 90 Massachusetts physicians working in 14 health centers — the new study rules out the explanation that black patients, by virtue of being poorer, are excluded from seeing the better quality doctors to which their white counterparts are more likely to have access.

Even when they were being treated by the same pool of physicians, whites were more likely than blacks to meet the commonly accepted cut-off point for long-term control over blood pressure (30 % v. 24%), over "bad" cholesterol (57% v. 45%), and over the blood-glucose measure, hemoglobin A1C (47% v. 39%). The researchers approached their data mindful of the need to ensure that any discrepancies were not simply the effects of what they term "sociodemographic factors": Comparing apples with apples — patients of the same gender, income-range and age — the white patients still fared far better.

The cause of the discrepancy, however, remains a mystery.

Although the researchers adjusted their data for factors such as obesity levels, these did not affect the racial disparity. Some might be tempted to see the data as reflecting racial discrimination among doctors, but that would probably result in a different pattern among different doctors. Instead, the discrepancy was common among all of the doctors, irrespective of how many black patients they saw or how good their overall performance rates were.

Furthermore, at least the initial patient-doctor interaction appeared to have been similar for all patients: rates of testing for blood-sugar control and for cholesterol, for example, were the same. "That suggests the physicians are implementing standard treatment plans," says Thomas Sequist, lead author of the study and an internist at Harvard Vanguard Medical Associates. It's only later, when it comes to treatment and, especially, outcomes, that a disparity is evident.

Sequist, for his part, has a hunch. He doesn't think most doctors discriminate at all. "I feel like the issue may more be that the doctors are treating all the patients the same — and if you treat all the patients the same you won't get the same outcomes because patients don't face the same challenges," he says. "We're not tailoring our counseling to the needs of our patients."

That's why Sequist did a follow-up study with the same group of physicians, asking whether they thought racial disparities were a problem in diabetes care. About 90% said there's a problem in the U.S. nationally, but less than half of that number believed the problem affects their own practices. Now, Sequist is giving those doctors reports on their treatment performance based on the race of the patient. He's also experimenting with what he calls "cultural competency training": lessons designed to help doctors recognize when patients may not share the same assumed health conditions, or when patients may face constraints that make the standard dietary and exercise guidance tougher to follow. Sequist emphasizes that these lessons are not aiming to teach doctors "what a black patient thinks," but to get doctors to find out what their patients actually do think. Results of the trial won't be available until later this year. But, if it works, it could be a huge boon to treatment for all kinds of chronic conditions. "I think the issues are all the same," Sequist says. "They're around medication adherence and patient engagement."