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Journal of General Internal Medicine

Published in:

01-06-2018 | Original Research

Longitudinal Analysis of Racial/Ethnic Trends in Quality Outcomes in Community Health Centers, 2009–2014

Authors: Megan B. Cole, PhD, MPH, Brad Wright, PhD, Ira B. Wilson, MD, Omar Galárraga, PhD, Amal N. Trivedi, MD, MPH

Published in: Journal of General Internal Medicine | Issue 6/2018

Abstract

Background

To monitor progress towards eliminating health disparities, community health centers have reported on hypertension control, diabetes control, and birthweight by race and ethnicity since 2008.

Objective

To evaluate racial/ethnic time trends in quality outcomes in health centers and to assess both within- and between-center disparities in outcomes.

Design and Sample

Using 2009–2014 data from all US health centers (n = 1047 centers, serving 19.6 million patients/year), we evaluated racial/ethnic time trends in quality outcomes for health centers and assessed within- and between-center disparities.

Main Measures

Percentage of patients achieving control of blood pressure < 140/90 mmHg among hypertensive persons, control of glycosylated hemoglobin ≤ 9.0% among diabetic persons, and birthweight ≥ 2500 g. All outcomes were reported by race/ethnicity.

Key Results

There was no evidence of improved outcomes among racial/ethnic subgroups from 2009 to 2014, though electronic health record adoption, medical recognition, and insurance coverage rates increased substantially. Two exceptions were increased rates of normal birthweight for black patients (87.0% to 88.8%, or 0.3 percentage points/year, p = 0.02) and decreased rates of diabetes control for white patients (74.2% to 69.5%, or −1.0 percentage points/year, p < 0.01). Within centers, the largest racial/ethnic disparities in 2009 were white/black disparities in hypertension control (8.7 percentage points, 95% CI 7.4–10.1), white/black disparities in diabetes control (3.4 percentage points, 95% CI 2.0–4.7), and white/Hispanic disparities in diabetes control (4.4 percentage points, 95% CI 2.8–6.0). All disparities remained statistically unchanged from 2009 to 2014. White patients were more likely to be seen at a health center in the top performance quintile compared with black and Hispanic patients (p < 0.001).

Conclusions

Though quality outcomes in health centers continued to compare favorably to other care settings, we found no evidence of improved quality or reduced disparities in diabetes control, hypertension control, or birthweight from 2009 to 2014. Within- and between-center racial/ethnic disparities in quality were evident, and both should be targeted in future interventions.

Available only for authorised users

Select health centers reported on birthweight by race/ethnicity prior to 2008, though reporting on diabetes control and hypertension control was required starting in 2008.

For a more detailed description of the Uniform Data System (UDS), including examples of prior literature using the UDS, please see Online Appendix.

This is in contrast to individual-level analyses, where patient numerators and denominators may be reported. Though we analyze compositional data, the underlying patient denominators exceed 10,000.

While the reporting threshold used by HRSA is ≤ 9%, which is reflective of the percentage of diabetic patients not exhibiting poor HbA1c control, the recommended range for adequate control is ≤ 7%, and thus the threshold used here is conservative.

Within-center disparities are unadjusted because health center characteristics are constant within a center for any given year for all two racial/ethnic groups, as data are reported at the health center level. Further stratified data within a health center by race/ethnicity are unavailable. While aggregate outcomes within any racial/ethnic group should be adjusted for confounding factors, within a center, disparities themselves (or rather, differences in outcomes between two racial/ethnic groups) should not be adjusted, as this would suggest that in some types of health centers with larger proportions of different types of patients, larger disparities are permissible.

See Online Appendix for example of prior research using a similar approach.

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Health Resources and Services Administration (HRSA). 2014 Health Center Data. Rockville (MD): HRSA; 2015. Available at: https://bphc.hrsa.gov/uds/datacenter.aspx?year=2014Accessed Dec 11, 2017.

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Title: Longitudinal Analysis of Racial/Ethnic Trends in Quality Outcomes in Community Health Centers, 2009–2014
Authors: Megan B. Cole, PhD, MPH
Brad Wright, PhD
Ira B. Wilson, MD
Omar Galárraga, PhD
Amal N. Trivedi, MD, MPH
Publication date: 01-06-2018
Publisher: Springer US
Published in: Journal of General Internal Medicine / Issue 6/2018
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-018-4305-1

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Abstract

Background

Objective

Design and Sample

Main Measures

Key Results

Conclusions

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