Improved Service Efficiency Improves Racial Disparity in Diabetic Care

Background: Racial disparities in diabetes care have been documented. Disparities also have been shown to affect service quality and outcome of diabetic care. Analysis of our internal medicine residency clinic diabetic care management performance across REAL-G (race, ethnicity, age, preferred language and/or gender) showed race-based disparity on two outcome measures: 1) measurement of glycohemoglobin (A1C) at least twice a year; and 2) target blood pressure of \u3c 140/90. Purpose: Develop interventions to decrease racial disparities in diabetes care among patients managed by an internal medicine residency clinic, as part of the Alliance of Independent Academic Medical Center’s National Initiative V project. Methods: Interventions were developed following analysis of clinic performance data by REAL-G categories, workflow analysis and multidisciplinary clinic team meetings. A point-of-care A1C machine was procured and workflow developed using the Plan-Do-Study-Act cycle. Staff training was conducted. A rolling 12 months data set was obtained from electronic health records. Baseline data range was December 2014 to November 2015, while endline data were from January 2016 to December 2016. The interventions were launched in July 2016. Percentage difference between baseline and endline outcome indicators was calculated and Z-score test assessed. Statistical significance was set at P \u3c 0.05. Results: At baseline, 62.9% (401 of 638) of patients who self-identified as African American/black (AA) had A1C measured at least twice a year compared to 74.3% (107 of 144) of patients who self-identified as white/Caucasian (WC), a percentage difference of 11.4% (P = 0.01). For goal blood pressure in diabetics, 71.0% (453 of 638) of AA met the target as compared to 80.6% (116 of 144) of WC, a percentage difference of 9.6% (P = 0.003). Following the intervention, a higher percentage of AA patients (71.4% [381 of 534]) had at least two A1C measured during project period. The outcome also showed improvement for WC (79.8% [95 of 119]). The percentage difference between races narrowed to 8.5% (P = 0.06). For goal blood pressure, 75.1% of AA achieved the target compared to 81.5% of WC, with percentage difference narrowing to 6.4% (P = 0.14). Conclusion: Racial disparities in diabetes were confirmed, even for a clinic setting in which black patients are predominant. Racial disparity can be improved by implementing interventions that improve service for all patients

Clinical features and prognosis of Type 2 Myocardial Infarction in acutely decompensated diabetic patients

BACKGROUND: After the introduction of the universal definition of myocardial infarction, the incidence and diagnosis of type 2 myocardial infarction have risen dramatically, yet there are no clear guidelines on clinical management. Diabetic patients are at high risk for developing type 2 myocardial infarction when admitted in a decompensated state, and they are also at high risk for future cardiovascular events. METHODS: We performed a retrospective analysis of 1058 patients admitted with diabetic ketoacidosis or hyperosmolar hyperglycemic state between 2011 and 2016. Patients were included if they had cardiac troponin I measured within 24 hours of admission, were older than 18 years of age, and had no evidence of acute coronary syndrome on admission. Baseline characteristics, admission laboratory test results, major adverse cardiovascular events, cardiac stress testing, and coronary angiography data up to 1 year after admission were reviewed. Patients were categorized into 2 groups: those with and those without type 2 myocardial infarction. The study had 2 endpoints: mortality and major adverse cardiac events (MACE) at 1 year and an abnormal result on stress test or coronary angiography at 1 year. RESULTS: Of the 845 patients who met the inclusion criteria, 133 patients (15%) had type 2 myocardial infarction on admission. Patients with type 2 myocardial infarction were at a significantly higher risk for mortality and MACE at 1 year than those without. Patients with type 2 myocardial infarction were also at higher risk for developing an abnormal result on stress test or coronary angiography within 1 year of admission as compared with those without type 2 myocardial infarction (40% vs 24%; odds ratio 2; P = .0699). CONCLUSION: Acutely decompensated diabetic patients with type 2 myocardial infarction are at increased risk for death and MACE. These patients may also be at risk for undiagnosed coronary artery disease