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Impact of quality improvement efforts on race and sex disparities in hemodialysis.
by Sehgal ARJAMA : the journal of the American Medical Association.
Article Abstract:
CONTEXT: By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue. OBJECTIVE: To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. DESIGN, SETTING, AND SUBJECTS: Longitudinal study of 58 700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000. INTERVENTION: Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers. MAIN OUTCOME MEASURES: Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level). RESULTS: The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P =.008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly. CONCLUSIONS: Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities.
Understanding expected patterns of changes in absolute differences between rates at which racial or gender groups receive adequate care
By: James Scanlan - Thu 5/31/2007 PMIn reaching this conclusion, however, Sehgal failed to consider the ways absolute differences between rates of adequate dose would tend to change solely because of increases in rates of adequate dose. The ways absolute differences tend to change as the overall prevalence of an outcome changes is somewhat complicated, and is explained in other places,[2,3] most fully in a Journal Review comment [4] on Vaccarino et al.[5]. But the rates in the latter years of Sehgal’s analyses were in the range where overall increases would be expected to reduce absolute disparities. Whether there occurred any change in disparities that were not solely a consequence of increasing overall rate of adequate dose would require a closer examination.
References:
1. Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA 2003;289:996-1000.
2 Scanlan JP. Can we actually measure health disparities? Chance 2006:19(2):47-51: http://www.jpscanlan.com/images/Can_We_Actual...
3. Scanlan JP. The misinterpretation of health inequalities in the United Kingdom. Paper presented at: British Society for Population Studies Annual Conference 2006, Southampton, England, Sept. 18-20, 2006: http://www.jpscanlan.com/images/BSPS_2006_Com...
4. Scanlan JP. Effects of choice of measure on determination of whether healthcare disparities are increasing or decreasing. Journal Review May 1, 2007: http://journalreview.org/view_pubmed_article....
5. Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med 2005;353:671-682.