Diabetes—Improved Service Efficiency Improves Racial Disparity

Background: Disparities are seen in diabetes management with poor outcomes in black/African American patients compared to white patients. Two of the 4 diabetic indicators showed racial disparity: at least 2 glycohemoglobin (A1c) checks per year and blood pressure control of <140/90 mmHg. Known strategies to reduce racial disparities in patients with diabetes include community engagement and patient empowerment, increasing access and improving care coordination, and improving the quality of care.

Methods: Patient disparities were identified using REAL-G categories (race, ethnicity, age, language, gender) from Epic analyses. Data collected through staff interview, group discussion, and a review of the workflow identified key barriers: on-time A1c ordering, patients staying for laboratory work, timely availability of laboratory results, and resident/staff workload. The optimal interventions identified and prioritized for diabetes mellitus targeted REAL-G disparities via literature and the healthcare team’s perceptions of available resources. An A1c testing machine was purchased, and the clinic workflow was streamlined for point-of-care/day of patient appointment access. Orientation and training were provided for residents, faculty, and staff. Resident and faculty clinic champions were available each day of the workweek. Numerous PDSA cycles were conducted with the leadership of the clinic staff to improve the workflow related to point-of-care/day of A1c access.

Results: The Internal Medicine Clinic showed an overall increase in diabetes mellitus measures from 2015 to 2016. Overall, the patients receiving twice-yearly A1c checks increased by 9%. This result was under goal, but the clinic no-show rate remained static at 30%, challenging further improvement. Among African Americans, the percentage of patients receiving twice-yearly A1c checks increased from 63% in 2015 to 71% in 2016. Among white patients, those receiving twice-yearly A1c checks increased from 74% in 2015 to 80% in 2016. Overall, the number of patients with blood pressure <140/90 mmHg increased by 2%.

Conclusion: Racial disparities exist in clinic settings where African Americans are the predominant customers. The disparities may be associated with overall service quality that can be improved by implementing interventions that improve service for all patients. The ability to sustain the project is increased through active involvement of clinic staff/leaders at project inception.