Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation.
Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation.
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DOI：
10.1371/journal.pone.0240306
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发表时间：
2020
期刊：
影响因子：
3.7
通讯作者：
Washington DL
中科院分区：
文献类型：
--
作者：
Leung LB;Steers WN;Hoggatt KJ;Washington DL
以患者为中心的医疗之家（PCMH）是改善护理可及性和人口水平健康结果的初级保健提供模式，但尚未观察到它们缩小了退伍军人健康管理局（VHA）或其他卫生系统中的种族-民族差异。我们的目的是确定和比较非西班牙裔黑人（黑人）和西班牙裔与非西班牙裔白色（白色）患者在VHA实施PCMH前后持续高血压和糖尿病控制差异的潜在驱动因素。2009年黑人和西班牙裔与白色VHA初级保健患者（n高血压= 26,906; n糖尿病= 21,141）和2014年（n高血压= 83，809;糖尿病= 38，887），我们回顾性检查了高血压控制，（血压<140/90）和糖尿病控制（血红蛋白A1 c <9）通过VHA的质量监测程序通过全国患者健康记录的随机图表提取获得。我们拟合线性概率回归模型，调整年龄，性别，合并症和社会经济地位（SES）。Blinder-Oaxaca和Smith-Welch分解方法被用来解析出解释和无法解释的贡献者之间的健康差异种族，民族群体之前和之后的PCMH实施。与白色患者相比，实施VHA PCMH后，黑人患者（分别为-6.2%<$0.4%]和-3.1%<$0.6%]; p <0.001）和西班牙裔患者（分别为-1.4%<$0.8%]和-4.0%<$1.0%]; p <0.001）的高血压和糖尿病控制率仍显著较低。大多数种族-民族差异（55.7-92.3%;所有p<0.05）不归因于年龄、性别、合并症和SES。解释与未解释因素的贡献并没有随着时间的推移显着变化。虽然退伍军人疾病控制中存在持续的种族-民族差异的许多解释，但我们的研究并没有发现这是由于PCMH实施后“生病”或“社会经济弱势”患者涌入VHA。相反，无法解释的差异可能是由于不同的医疗保健和社区经验（例如，歧视）。了解导致健康差异的潜在途径将更好地为政策和临床干预提供信息，以改善卫生系统中少数种族患者的PCMH护理服务。
Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA’s quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p’s<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p’s<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7–92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of “sick” or “socioeconomically vulnerable” patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.
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影响因子：
39.2
作者：
Kind AJ;Jencks S;Brock J;Yu M;Bartels C;Ehlenbach W;Greenberg C;Smith M
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