Race, Ethnicity, Socioeconomic Position, and Quality of Care for Adults With Diabetes Enrolled in Managed Care The Translating Research Into Action for Diabetes (TRIAD) study ARLEEN F. BROWN, MD, PHD 1 EDWARD W. GREGG, PHD 2 MARK R. STEVENS, MSPH, MA 2 ANDREW J. KARTER, PHD 3 MORRIS WEINBERGER, PHD 4,5 MONIKA M. SAFFORD, MD 6 TIFFANY L. GARY, PHD 7 DOROTHY A. CAPUTO, APRN, BC-ADM 8 BETH WAITZFELDER, PHD 9 CATHERINE KIM, MD, MPH 10 GLORIA L. BECKLES, MD, MSC 2 OBJECTIVE — To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS — We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA 1c [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS — Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had sim- ilar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS — In these managed-care settings, minority race/ethnicity was not consis- tently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of di- lated eye examinations. Social disparities in health may be reduced in managed-care settings. Diabetes Care 28:2864 –2870, 2005 P opulation-based studies suggest that racial and ethnic minorities (1– 6) and people of lower socioeconomic position (SEP) (2) experience worse long- term outcomes for diabetes than whites and people of higher SEP. However, it is unclear why these differences persist even among individuals with health insurance. Understanding the relationship of race/ ethnicity and SEP to processes and out- comes of diabetes care in insured populations is critical to reducing health disparities. Previous research found poorer pro- cesses of diabetes care (e.g., performance of dilated eye examinations and foot ex- aminations at regular intervals) and inter- mediate health outcomes (e.g., control of glycemia, blood pressure, or lipid levels) among racial and ethnic minorities and individuals of lower income or education (2,3,7–14). As racial and ethnic minori- ties and poorer people with diabetes are less adequately insured than whites or wealthier people (15,16), differential ac- cess to care may contribute to these find- ings. Research from managed-care settings (17,18) and the Veterans Health Administration (19,20) suggests that ra- cial and ethnic disparities in diabetes pro- cesses and outcomes may be reduced in settings offering more uniform access to care. These studies were conducted in single systems of care, however, and it is not known whether similar reductions in health disparities can be achieved in man- aged-care settings that are more clinically and geographically heterogeneous. Addi- tionally, the studies of insured popula- tions did not explicitly evaluate the impact of SEP, separate from race/ ethnicity, and did not examine whether disparities in intermediate outcomes were ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; the 2 Centers for Disease Control and Prevention, Atlanta, Georgia; the 3 Division of Research, Kaiser Permanente, Oakland, California; the 4 De- partment of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the 5 Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina; the 6 Deep South Center on Effectiveness at Birmingham VA Medical Center and Department of Preventive Medicine University of Alabama at Birmingham, Birmingham, Alabama; 7 Department of Epide- miology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; the 8 Univer- sity of Medicine and Dentistry of New Jersey Continuing and Outreach Education, New Brunswick, New Jersey; the 9 Pacific Health Research Institute, Honolulu, Hawaii; and the 10 Departments of Medicine and Obstetrics-Gynecology, University of Michigan, Ann Arbor, Michigan. Address correspondence and reprint requests to Arleen F. Brown, MD, PhD, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1736. E-mail: abrown@mednet.ucla.edu. Received for publication 19 May 2005 and accepted in revised form 1 September 2005. Abbreviations: CHD, coronary heart disease; DBP, diastolic blood pressure; MCS-12, Mental Compo- nent Summary; PCS-12, Physical Component Summary; SBP, systolic blood pressure; SEP, socioeconomic position; TRIAD, Translating Research Into Action for Diabetes. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2005 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E 2864 DIABETES CARE, VOLUME 28, NUMBER 12, DECEMBER 2005