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Thomas D. Sequist, MD, MPH; Garrett M. Fitzmaurice, ScD; Richard Marshall, MD; Shimon Shaykevich, MS; Dana Gelb Safran, ScD; John Z. Ayanian, MD, MPP

Arch Intern Med. 2008;168(11):1145-1151.

Background  Little information is available regarding variations in diabetes mellitus (DM) outcomes by race at the level of individual physicians.

Methods  We identified 90 primary physicians caring for at least 5 white and 5 black adults with DM across 13 ambulatory sites and calculated rates of ideal control of hemoglobin A_1c (HbA_1c) (<7.0%), low-density lipoprotein cholesterol (LDL-C) (<100 mg/dL), and blood pressure (<130/80 mm Hg). We fitted hierarchical linear regression models to measure the contributions to racial disparities of patient sociodemographic factors, comorbidities, and physician effects. Physician effects modeled the extent to which black patients achieved lower control rates than white patients within the same physician's panel ("within-physician" effect) vs the extent to which black patients were more likely than white patients to receive care from physicians achieving lower overall control rates ("between-physician" effect).

Results  White patients (N = 4556) were significantly more likely than black patients (N = 2258) to achieve control of HbA_1c (47% vs 39%), LDL-C (57% vs 45%), and blood pressure (30% vs 24%; P < .001 for all comparisons). Patient sociodemographic factors explained 13% to 38% of the racial differences in these measures, whereas within-physician effects accounted for 66% to 75% of the differences. Physician-level variation in disparities was not associated with either individual physicians' overall performance or their number of black patients with DM.

Conclusions  Racial differences in DM outcomes are primarily related to patients' characteristics and within-physician effects, wherein individual physicians achieve less favorable outcomes among their black patients than their white patients. Efforts to eliminate these disparities, including race-stratified performance reports and programs to enhance care for minority patients, should be addressed to all physicians.

Author Affiliations: Division of General Medicine and Primary Care, Brigham and Women's Hospital (Drs Sequist, Fitzmaurice, and Ayanian and Mr Shaykevich), Department of Health Care Policy, Harvard Medical School (Drs Sequist and Ayanian), Harvard Vanguard Medical Associates (Drs Sequist and Marshall), The Health Institute, Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center (Dr Safran), and Blue Cross Blue Shield of Massachusetts (Dr Safran), Boston.

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