Our study advances the literature on racial/ethnic disparities in quality of care for patients with diabetes. We assessed racial/ethnic disparities in the quality of diabetes care on the basis of receipt of recommended HbA1c tests and foot and eye examinations in the previous year. We hypothesized that racial/ethnic minority patients with diabetes would receive lower quality of care than their white counterparts. Compared with white patients with diabetes, Asian patients with diabetes were less likely to have received at least 2 HbA1c tests and both Asian and Hispanic patients were less likely to have received a foot examination in the past 12 months. Conversely, black patients with diabetes were more likely to have received a foot examination in the past 12 months compared with white patients with diabetes. This finding may be explained by the fact that black patients with diabetes tend to have higher rates of diabetes complications and amputations, and recent guidelines have highlighted the need to carefully monitor these patients as their conditions progress (22
). These differences remained significant even after controlling for SES, insurance status, health status, comorbid conditions, and lifestyle behavior variables.
However, our results differ from those found by Lee and colleagues (19
), who found no differences in receipt of these measures among racial/ethnic minorities. Their analysis of 2000 MEPS data found no differences among racial/ethnic groups for most of the outcomes in diabetes care management, including respondents who had received an HbA1c test, had their feet checked for sores or irritation, or received an eye examination in the past year. A possible explanation for the different findings may be differences in study design. Contrary to the study conducted by Lee et al (19
), we restricted our sample to unique individuals to compute appropriate standard errors in pooled estimations. Additional differences were the use of more recent data sets, the use of special diabetes weights from MEPS, and the use of the balanced repeated replication method variance estimation to account for the full set of survey stratum and primary sampling units, as recommended by MEPS (23
). Our results also differ from findings of a study by Trivedi et al that found narrowing of the gap in the quality of diabetes care between whites and blacks (14
). However, this study was limited to Medicare beneficiaries in managed care, and the authors did not stratify by other racial/ethnic minority groups such as Hispanics and Asians. The findings by Trivedi et al may not be generalizable to other health systems or to other racial/ethnic groups that may experience greater racial/ethnic disparities in the quality of diabetes care. Conversely, our findings are consistent with those of other studies that used both clinical and community-based data (24
Our study has limitations. First, the data we used were cross-sectional, so causal relationships cannot be established. Second, the dependent variables were self-reported measures of process outcomes of diabetes care. Although we controlled for patients who reported poor or fair health or comorbid cardiovascular conditions, these patients may have visited their providers more often and thus were more likely to receive diabetes tests compared with those who reported excellent or good health and no comorbid cardiovascular conditions. Furthermore, no information on glycemic control among patients with diabetes was available. Asians may have better glycemic control and may have received HbA1c tests and foot and eye examinations less frequently than their white counterparts.
Although the link between racial/ethnic minority status and the quality of care for patients with diabetes is not completely understood, our study suggests that factors such as health insurance status, SES, and self-rated health status are potential antecedents of quality of diabetes care. Therefore, assessing the association between racial/ethnic disparities in the quality of diabetes care and factors such as SES, insurance status, and health behaviors is warranted because these factors are modifiable and can serve as the focus of interventions to reduce racial/ethnic disparities in the quality of diabetes care. Findings from this study may have clinical, public health, public policy, and research implications. Specifically, these results may underscore the importance of providing diversity training to providers to improve the quality of care to patients with diabetes. Furthermore, evidence from this study may play a key role in informing policy makers in their continuous efforts to translate effective research into nationwide practices to eliminate racial/ethnic differences in quality of care, which is relevant in the context of the current health care reform law that seeks to eliminate racial/ethnic disparities. Additional research is needed to fully evaluate the mechanisms and sources of racial/ethnic disparities in the quality of diabetes care.