A Qualitative Review of Studies of Diabetes Preventive Care Among Minority Patients in the United States, 1993-2003

Objective: To review existing data to determine whether ethnicdisparities exist for diabetes-related preventive care among adultsin the United States.

Study Design: Literature review.

Methods: We identified diabetes-related studies publishedbetween 1993 and 2003, using a reproducible search strategy.Studies were selected for review if there were ethnic comparisonsor if data on a specific ethnic minority were reported. From thesestudies, we extracted data on commonly accepted diabetes-relatedpreventive-care measures (testing for glycemia, eye examinations,foot examinations, lipid profile, influenza vaccination, nephropathyassessment, smoking-cessation counseling). The sources wereUS healthcare facilities, national survey samples, Veterans Affairsfacilities, Medicare databases, and managed care data.

Results: Thirty-six studies met our search criteria. Data wereextracted on glycemia testing (15 studies), eye examination rates(27 studies), foot examination rates (18 studies), lipid-profileassessment (15 studies), percentage of patients receiving influenzavaccinations (8 studies), nephropathy assessment (7 studies), andcounseling referrals for smoking cessation (4 studies). The majorityof the data indicated that the rates of diabetes monitoring are generallylow regardless of the population being studied. The majorethnic differences reported were lower rates of eye examination,influenza vaccination, and lipid-profile testing among Hispanicsand African Americans than among non-Hispanic whites.

Conclusions: Despite the availability of evidence-based guidelines,rates of diabetes preventive care are low, particularly forsome measures in ethnic minority groups. Additional data areneeded to further elucidate these disparities.

(Am J Manag Care. 2005;11:349-360)

Diabetes contributes significantly to morbidity,mortality, and healthcare expenditures; and itsprevalence is increasing rapidly in the UnitedStates. Some ethnic minority groups, such as AfricanAmericans, Hispanics, and American Indians, are disproportionatelyaffected by high prevalences of diabetesand diabetes-related complications.^1,2 Evidence-basedguidelines for clinical management of diabetes are availableto prevent or delay these complications, includingthose published annually by the American DiabetesAssociation.³ These guidelines include recommendationsto measure diabetes patients' degree of glycemiccontrol, their blood pressure, and their lipid levels; toconduct foot and dilated eye examinations; to assesspatients' urinary protein; to ensure that patients receiveinfluenza vaccination; and to provide patients withlifestyle counseling on diet, exercise and weight control,and smoking cessation.³ Other guidelines, such as thoseof the Diabetes Quality Improvement Project⁴ and thosein the Health Plan Employer Data and Information Set,⁵are used to assess the quality of care provided topatients with diabetes. Higher rates of physician performanceof preventive-care measures have been shownto correspond to better control for diabetes managementcompliance.⁵

Despite the availability of such guidelines and quality-of-care measures, there is an overall lack of adherenceto these guidelines by healthcare providers.⁶Research has shown that certain populations, especiallyethnic minority groups, are less likely to receive thehighest level of healthcare, especially for preventiveservices such as influenza vaccination and cancerscreening.^7-9 However, ethnic disparities in diabetespreventive care have not been adequately defined. Thisqualitative review synthesizes the body of research overthe past decade on diabetes quality of care across ethnicminority populations in the United States, as thatquality is related to well-established diabetes preventive-care measures. These measures also have beenreferred to as processes of care, quality indicators, andstandards of care. For this review, preventive-caremeasures include tests for glycemia (glycosylatedhemoglobin or A_1c), eye and foot examinations, lipidprofile, influenza vaccination, nephropathy assessment,and smoking-cessation counseling.

METHODS

We conducted a MEDLINE search on PubMed for diabetesstudies done in the United States and publishedfrom 1993 to 2003, as part of a systematic review for alarger study on ethnic disparities in diabetes quality ofcare. Other data sources searched included Web ofScience, Education Resources Information Center,Cumulative Index to Nursing and Allied Health,Combined Health Information Database, and theCochrane Library. Studies involving patients with pre-diabetes,patients younger than 18 years of age, patientswith impaired fasting glucose, or women with gestationaldiabetes were excluded. We "exploded" the MedicalSubject Heading (MeSH) term "diabetes mellitus" into its2 components (diabetes mellitus, insulin dependent; anddiabetes mellitus, non-insulin dependent) and used theseterms along with free text to capture terms not found asMeSH headings, such as literacy, immigration status,locus of control, and insurance. To evaluate the quality ofdiabetes care in ethnic minority groups, we used searchterms including diabetes, preventive measures, processesof care, and quality of care. We then extracted studieswith a focus on ethnic minorities, as indicated by theiruse of the terms "race/ethnicity/ethnology," "ethnicgroups," or "minority groups." We repeated the searchprocess without restricting the search to MeSH headingsin order to capture free-text articles.

We imported references into a database (ReferenceManager, version 10, ISI Research Soft, Berkeley, Calif)and deleted duplicate references. Primary reviewers(JKK and RAB) reviewed reference lists from citationsfor additional studies that met inclusion criteria. Allstudies containing process measures for preventive careof diabetes were included as long as there were minority-group comparisons and/or a minority populationwith diabetes was studied. Observational and interventionstudies were included to be comprehensive.

Literature Review Process

We identified 450 abstracts that met our initial criteria.We then assessed the articles summarized by theseabstracts to determine whether they contained diabetespreventive-care measures. Studies were included if dataspecific to an ethnic minority group were reported or if anethnic minority group was compared with a non-Hispanicwhite group. Ethnic minority populations were classifiedas African American, American Indian/Alaska Native,Asian/Pacific Islander, and Hispanic. The latter categoryincluded persons whose country of origin was Central orSouth America, the Caribbean Islands, or Mexico. Whereindicated, we included the terms "Hispanic black," "Hispanic white," "non-Hispanic black," and "non-Hispanic white." After excluding articles that did not meetinclusion criteria, a total of 390 full-text articles wereretrieved, of which 36 had data specific to ethnic minoritypopulations regarding preventive-care measures.

Data on performance of preventive-care measuresare reported in table format by ethnic group and comparedwith corresponding data for non-Hispanic whites(when provided). When evaluating multiple ethnicminority groups we compared each with the non-Hispanic white group. Information for non-Hispanicwhite groups was repeated in the table if there weremultiple ethnic groups in a given study. We also documentedwhether data on preventive-care measures werebased on patients' self-report or were obtained frommedical chart reviews.

RESULTS

The data from 35 studies that reported annual(unless otherwise specified) assessment of diabetes preventive-care measures are listed in Tables 1 through 5.One study not included in the tables is described in thetext because specific percentages were not provided forthe preventive measure. Data were extracted onglycemia testing (15 studies), eye examination rates (28studies), foot examination rates (18 studies), lipid-profileassessment (15 studies), percentage of patientsreceiving influenza vaccinations (8 studies), nephropathyassessment (7 studies), and counseling referrals forsmoking cessation (4 studies). Eighteen of the 36 studiesprovided data on multiple preventive-care measures.Twenty-five studies used medical chart review data, 10used self-reported information, and 1 study used both.

Glycemia Testing

Of the 15 studies that provided data on glycemiatesting (Table 1), 10 included African Americans,^10-19 2included American Indians,^20,21 and 4 includedHispanics.^16,22-24 One study had both African Americansand Hispanics.¹⁶ Ten of the 15 studies had a non-Hispanic white comparison group, and 5 of those conducteda statistical comparison by race/ethnicity.Excluding studies that provided rates other than annually,the range in glycemia testing rates was 19% to 87% forAfrican Americans with a median of about 60%. Whenmore frequent testing was expected for quarterly assessmentof glycemia among African American insulin users,the rate was only 8.1%, while semiannual assessment ofglycemia was 26.4% for African Americans not usinginsulin.¹⁹ The annual testing rate among AmericanIndians was 79.6% in a national study and 64% semiannuallyin a regional study.^20,21 Among Hispanics, the rateof annual glycemia testing ranged from 37.6% to 88.4%,with an estimated median of about 63% for these studies.^22,24 Rates of glycemia testing in a 2-year period were30.7% in one study, while the rate for receiving 2glycemia tests in a 2-year period was 41.4% in anotherstudy.^16,23

Three studies showed lower rates of glycemia testingamong African Americans compared with non-Hispanicwhites.^10,13,17 The largest study of glycemia testingshowed a 6% lower rate of annual glycemia measurementamong African American (66%) compared with non-Hispanic white (72%) Medicare recipients (n = 80 532)in North Carolina.¹⁷

Eye Examination

For eye examination rates (n = 28) (Table 2), datawere available from 19 studies that included AfricanAmericans,^{6,8,10-18,25-31,37} 4 with American Indians,^20,21,32,33 and 10 with Hispanics.^{6,16,22,24,28,29,34-37} Sixstudies had data for multiple ethnic minoritygroups.^{7,16,28,29,37,38} Studies included performance of adilated eye examination by a healthcare professional ora visit to an eye-care professional. Of the 13 studies witha non-Hispanic white comparison group,* 9 conducted astatistical comparison by race/ethnicity.†Among studiesreporting annual rates of eye examination, data werehighly variable for each ethnic group, with a range of 7%to 82% (estimated median 50.4%) among AfricanAmericans, 14% to 75% (estimated median 57%) amongAmerican Indians, and 28% to 84% (estimated median60.8%) among Hispanics.

Five studies found statistically significant differences(as large as 7.9%) by race/ethnicity,^{8,10,13,22,30} with all ofthem showing a lower rate of eye examinations in theethnic minority group than among non-Hispanic whites.In one of these studies, Schneider and collegues,⁸ usingnational Medicare managed care data, showed significantlylower rates of eye examinations among AfricanAmericans (43.6%) than among non-Hispanic whites(50.4%). In another, Wang and Javitt³⁰ found significantlylower rates of use of eye-care services amongAfrican American (45.7%) compared with white (53.6%)Medicare beneficiaries. Another study showed rates of71% for African Americans for self-reported eye examinationin a 2-year period.³¹ One study showed rates of82.8% for both African Americans and Hispanics for eyeexamination referral in a 2-year period.¹⁶

In an analysis of National Health Interview Surveydata, Cowie and Harris³⁷ found no significant differencesin rates of self-reported receipt of eye care forAfrican Americans and for Hispanics. However, anotherstudy showed higher rates of eye exams amongHispanics (80.8% to 84%) than among non-Hispanicwhites (76.3%).²² An analysis of Behavioral Risk FactorSurveillance System data from 1995 to 2001 showed anincrease in self-reported annual eye examination of5.9% among non-Hispanic whites (62.4% to 68.3%) anda 14% increase among Hispanics (46.1% to 60.0%), whilerates for non-Hispanic blacks declined during the sametime period (69.0% to 63.8%).⁶

A recent study among veterans (429 928 patients)evaluated ethnic differences in diabetes complications.Although eye examinations were reported, thefrequency of the exams was not defined.³⁸ Among theethnic groups considered in this study (AfricanAmerican, Hispanic, Asian, and Native American),rates of eye examination were 51.4%, 43.1%, 53.2%,and 47.6%, respectively, compared with a rate of 50.5%among non-Hispanic whites. Rates for Hispanics andNative Americans were significantly lower than therate for non-Hispanic whites, while the rate for AfricanAmericans and Asians was significantly higher.

Foot Examination

Studies providing data on foot examinations (n = 18)(Table 3) included 11 with African Americans,^‡5 withAmerican Indians,^{20,21,31,32,40} and 5 with Hispanics.^{6,16,22,24,29} Three studies had both African Americansand Hispanics.^6,16,29 We reviewed studies reporting anylevel of foot examination, including a complete or partialfoot examination (visual inspection, pedal pulse examination,and a sensory examination). Rates varied extensivelybased on the type of foot examination reported. In6 studies comparing foot examination rates amongAfrican Americans with those among non-Hispanicwhites, no statistically significant differences werefound. None of the studies we reviewed compared footexamination rates among American Indians with thoseamong other ethnic groups. One report comparing ratesin 1995 and 2001 showed that the foot examinationrates for Hispanics declined 8.2% (62.9% to 54.7%) duringthis period, while rates for African Americansincreased by 16.1% (54.1% to 70.2%) and rates for non-Hispanic whites increased by 8.7% (52.7% to 61.4%) duringthe same period.⁶

Lipid Profile

Studies reporting rates of lipid profiles (n = 15) (Table4) were evaluated from 11 studies with AfricanAmericans,^11-19,28,29 3 with American Indians,^20,21,33 and 4with Hispanics.^16,22,28,29 Three contained data for bothAfrican Americans and Hispanics.^16,28,29 There was widevariation in the percentage of ethnic group membersamong whom lipid profiles were done (37% to 86% witha median of about 65%). Of the 9 studies that comparedrates with those among non-Hispanic whites, 6 foundthat minority populations received lipid profilesless frequently than their white counterparts,with the differences ranging from -3.4% to as muchas -19%.^{13,15,17,19,28,29} Three of these studies showed statisticallysignificant differences.^15,19,28 Harris and colleagues,using data from the National Health andNutrition Examination Survey III, found an annual lipid-profile rate of 68.1% among African Americans and61.8% among Hispanics, compared with 80.8% amongnon-Hispanic whites, a difference of -12.7% and -19%,respectively.²⁸

More recent data showed that the rate of low-densitylipoprotein laboratory testing among Department ofVeterans Affairs enrollees was 68% among AfricanAmericans compared with 83% among non-Hispanicwhites, a -15% difference.¹⁵ Three studies reported thatlipid-profile measurement was done more frequentlyamong a minority population compared with non-Hispanic whites, but not at a significantly higherrate.^11,16,22 Wisdom and colleagues¹⁹ split the samplebeing studied into 2 groups: insulin users and non-insulinusers. They found that African Americaninsulin users were more likely to get a lipid-profileassessment compared with non-insulin users; however,among non-insulin users, there was no significant differencecompared with non-Hispanic whites (59.4% vs62.8%, respectively).

Influenza Vaccination

Studies assessing rates of influenza vaccination (n =8) (Table 5) included 5 among African Americans,^{6,13,17,41,42} 2 with American Indians,^32,33 and 3 withHispanics.^6,22,42 Two studies had both African Americansand Hispanics.^6,41 All of the studies with AfricanAmericans and Hispanics reported comparative datawith non-Hispanic whites. Of the 5 studies withAfrican Americans, 3 showed significantly lower ratesamong African Americans (between 8.1% and 29%)than among non-Hispanic whites.^13,41,42 The percentageof patients receiving influenza vaccination variedwidely (from 16% to 73%) with an interval midpointof approximately 37% (33% to 41%).

In the largest study, Massing et al¹⁷ reported vaccinationrates among North Carolina Medicare beneficiariesto be 33% for African Americans and 54% fornon-Hispanic whites, a difference of -21%. One of the 3studies among Hispanics in which statistical tests wereperformed showed significantly lower rates of influenzavaccination among Hispanics than among non-Hispanic whites, as much as a -13% difference.⁴¹ Awider range of influenza-vaccination rates wasobserved in these studies among Hispanics (38% to66%) than among non-Hispanic whites (46% to 68%).

Nephropathy Assessment

Studies on nephropathy (n = 7) assessment are notincluded in table format. There were 4 with AfricanAmericans,^11-13,17 2 with American Indians,^20,21 and 1with Hispanics.²² None of these studies had multipleethnic minority groups. Four studies^11,15,17,22 had a non-Hispanic white comparison group, and 3 conductedtests of statistical significance across ethnicgroups.^11,15,22 Of these 3 studies 2 showed higher rates ofnephropathy assessment among African Americanscompared with non-Hispanic whites (7.1% and 11% difference).^11,15 Heisler and colleagues¹⁵ found the 2-yearnephropathy-assessment rates among AfricanAmericans (63%) to be higher than among non-Hispanicwhites (52%) receiving care in US Veterans Affairs facilities.However, this difference was not statistically significantafter adjustment for patient characteristics(patient's diabetes self-management, age, education,income, diabetes duration, severity of comorbidities,insulin usage or receiving more than 80% of care at aVeterans Affairs facility, or more than 2 visits in the lastyear). Massing and colleagues¹⁷ showed a 4% absolutelower rate of nephropathy assessment among AfricanAmerican Medicare recipients (49%) compared withtheir non-Hispanic white counterparts (53%).

Smoking-cessation Counseling

Studies on smoking-cessation counseling (n = 4)included 4 with African Americans^14,16,22,43 and 2 withHispanics.^16,43 Two studies had both African Americansand Hispanics.^16,43 The data for this preventive-caremeasure varied from documentation of healthcareproviders offering smoking-cessation counseling todocumentation of rates of patient smoking cessation.Sample sizes ranged from 42 to 1453 for minoritiesand 119 to 294 for non-Hispanic whites. None of thesestudies showed significant ethnic differences in counselingrates.

DISCUSSION

The purpose of this review was to examine the availabledata to determine the extent to which ethnic disparitiesexist regarding diabetes preventive-carepractices in the United States. We found that the largestethnic disparities reported were in the overall rates ofeye examination, lipid-profile testing, and influenza vaccinationamong African Americans and Hispanics. Thestudies we evaluated in this review also illustrate widevariation in the performance of these routine preventive-care measures for patients with diabetes.

One limitation of the studies in this qualitativereview is the reliance on medical charts. With theadvent of computerized medical records, these datamay be more easily obtainable. Another limitation isthat literature could have been omitted if author indexingof key words and titles was not descriptive of quality-of-caremeasures. There also were variations acrossstudies in the definition of measures (eg, visual footexamination vs complete foot examination) and how frequentlythe measures were performed (eg, semiannually,annually, biannually). In reviewing lipid-profile assessment,studies did not consistently clarify whether cholesteroltesting included a complete profile (totalcholesterol, low-density lipoprotein, high-density lipoprotein,and triglycerides) or just 1 component of the profile.

Our ability to provide pooled estimates was restrictedby the wide range in the ages of the patients studiedand heterogeneity in study design. The patient populationsalso were not homogenous; therefore, it is difficultto adjust for the case mix. These confounders limitedthe possibility of making comparisons across studies.Some ethnic minority groups were represented in onlya few studies, and no data were found for diabetes monitoringamong Asian/Pacific Islanders. As most of thedata for American Indians came from the Indian HealthService, no comparison data are available. With regardto ethnicity, the term "Hispanic" is not well defined insome of the studies cited and could refer to Latinos fromCentral and South America or the Caribbean. Some literaturealso cited Mexican Americans. With thisnomenclature in mind, there are pitfalls in adequatelydescribing and differentiating these groups. Finally,there was no information on socioeconomic factors,which might influence receipt of preventive care.

Despite these limitations, we found ethnic differencesin rates of obtaining certain routine preventive-caremeasures among patients with diabetes. Someearlier reports explain some of the variability we foundin this review. In a study of racial disparity in influenzavaccination rates, Schneider et al⁹ reported that commonreasons for patients not receiving the vaccineincluded not knowing it was needed, fearing it wouldcause either the flu or other adverse effects, and notbelieving that the vaccine would prevent flu. Other literatureindicates that minority groups tend to have lessaccess to healthcare services.^13,26 After Heisler and colleagues¹⁵adjusted for patient age, education, income,insulin use and diabetes self-management, the durationand severity of the diabetes, comorbidities, and healthservices utilization, they still found racial disparities inthe rates of assessment of low-density lipoprotein.

Many potential barriers to care have been identified.Language may be one of these barriers, as nearly 8 millionHispanics in the United States do not speak Englishwell and more than 1 in 4 households of Hispanics arelinguistically isolated.⁴⁴ In a study of English-speakingversus Spanish-speaking Latinos, 32% of Spanish-speakingLatinos reported that they needed a translatorand 23% reported language as a barrier with their primarycare provider.²² In a nationally representativesample of 4811 African Americans, 3379 Hispanics,and 33 737 non-Hispanic whites with private or publichealth insurance, African Americans and Hispanics hadgreater access to primary care in managed care plans.⁷In this study, however, Hispanics and AfricanAmericans had less access to specialty care than non-Hispanic whites.⁷ Lack of insurance has been cited asthe most significant barrier to care in rural and ethnicminority Americans, as they are less likely to havehealth insurance than non-Hispanic whites, with thehighest percentage of uninsured individuals amongHispanics (estimated at 35%).⁴⁴

Healthcare provider bias has been shown to influencethe quality of care. A recent cross-sectional analysisof 150 391 visits of black and white Medicarebeneficiaries revealed that physicians treating blackpatients had more difficulty obtaining subspecialists,diagnostic imaging, and nonemergency admission tothe hospital.⁴⁵

CONCLUSION

Diabetes greatly increases the risk for death, cardiovasculardisease, end-stage renal disease, diabeticretinopathy, and lower-extremity amputation.⁴⁶ Toprevent these complications, diabetes patients are recommendedto have regular monitoring and evaluationof A_1c levels (ie, glycemic control), blood pressure,lipids, and kidney, eye, and peripheral nerve functioning.³ Other preventive measures, such as influenza vaccinationand smoking cessation, are also stressed to thepatient on a regular basis.

Data from studies of other chronic diseases indicatethat ethnic minorities are less likely than non-Hispanic whites to receive appropriate screening, secondaryprevention care, and monitoring of high-riskpatients.^47-52 Reasons that patients do not obtain theseservices are not clear, but are believed to be associatedwith both physician and patient characteristics.^44,45For primary care providers, access to clinicalresources, physician training, and clinical inertia mayplay a role.⁵³ Empirical evidence suggests that thepresence of bias or prejudicial attitudes among healthcareproviders along with clinical uncertainty andbeliefs held by the provider may contribute to disparitiesin minority populations.^44,54 Patient-level variablesthat may contribute to racial disparities include mistrustof the medical system, refusal of recommendedservices, poor adherence to treatment regimens, anddelay in seeking care.

More aggressive adherence to preventive-care measuresis needed among all ethnic groups. Over the 10-year period evaluated in this review, the overallpercentage of patients receiving diabetes-related preventive-care services remained suboptimal. Our findingsfurther indicate that ethnic disparities in receivingdiabetes preventive-care services were most pronouncedfor eye exams, lipid profiles, and influenzavaccination in both African Americans and Hispanics.These results stress the need for more emphasis onquality improvement among primary care providersand for a better understanding of barriers that preventpatients, especially minority patients, from receivingoptimal diabetes monitoring and care.

Acknowledgment

We thank Ms. Carol Hildebrandt for her expertise in completing literaturesearches, assembling the references, and editing this manuscript.

From the Department of Family and Community Medicine (JKK, TAA), theDepartment of Public Health Sciences (RAB, AGB, SAQ, DCG), and the Department ofInternal Medicine (AGB, DCG), Wake Forest University School of Medicine, Winston-Salem, NC; and the Centers for Disease Control and Prevention, Atlanta, Ga (KMVN).

This study was made possible through a cooperative agreement between the Centersfor Disease Control and Prevention and the Association of Teachers of Preventive Medicine(award TS-0778).

The contents of this article are the responsibility of the authors and do not necessarilyreflect the official views of Centers for Disease Control and Prevention or the Association ofTeachers of Preventive Medicine.

Address correspondence to: Julienne K. Kirk, PharmD, CDE, Associate Professor,Department of Family and Community Medicine, Wake Forest University School ofMedicine, Medical Center Boulevard, Winston-Salem, NC 27157-1084. E-mail:jkirk@wfubmc.edu.

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