Cultural competency training didn't change disparities in diabetes care

Training and feedback designed to make primary care providers more sensitive to racial differences in diabetes care increased clinicians' awareness but did not improve the health of their black patients, according to a Boston study appearing in tomorrow's Annals of Internal Medicine.

A large body of research has shown that black people with diabetes are less likely to have their disease adequately controlled, part of a larger picture in which health care disparities between black and white patients persist. An influential 2007 study by Dr. Alexander R. Green of Massachusetts General Hospital related unconscious bias to inferior care. Fewer studies have looked at measures to counteract racial gaps, prompting researchers led by Dr. Thomas Sequist of Harvard Vanguard Medical Associates and Brigham and Women's Hospital to examine the effect of such programs.

For their study of more than 5,000 patients, the researchers randomly assigned 31 primary care teams of doctors, nurse practitioners, and physician assistants either to a group following standard practices or to a group that received intensive training on cultural competency and feedback on their patients' progress designated by race. At the beginning of the trial, providers were asked whether they thought racial disparities existed in their practices. Patients' blood sugar, cholesterol levels, and blood pressure were tracked.

After 12 months, 63  percent of the team members who got training and feedback said they saw disparities in their practices compared to 43 percent of the other team members, but there was no difference in patient outcomes between the two groups. "We were able to increase awareness, but ... that didn't translate into improvements in clinical outcomes for black patients with diabetes," Sequist said in an interview.

That doesn't mean cultural competency training or performance reporting should be abandoned, he said. "It means they need to be combined with other programs that are perhaps even broader-reaching to really improve clinical outcomes."

Racial differences in income, education, employment, and availability of healthy grocery stores and safe exercise venues may play a role outside the doctor's office that could be addressed by nutritionists, social workers, and others working with primary care teams, Sequist suggested.

Dr. JudyAnn Bigby, Massachusetts secretary of health and human services and a specialist in health care disparities, said the training shouldn't be abandoned, but its limitations should be recognized. She was not involved in the study.

"Thinking about disparities resulting from individual interactions that patients have with individual providers I think is too narrow a way of thinking about what might be disparities in the quality of care," she said in an interview.  "The overall impact of  what a provider does in the office has to be understood in context with some of the other [parts of the] health system and the circumstances in the community in which people are living."

Bigby called the improved awareness of disparities "an important first step. ... We certainly  shouldn't abandon the concept that we need training, but this training may not have been adequate."