Authors
Apoorva Gupta; Ana Bermúdez, MD; Karina Whelan, MD
Introduction
Health equity has become an increasingly prevalent target of quality improvement (QI) projects across all disciplines of medicine. As attempts to model the drivers of inequity are being developed, it has become clear that care gaps must be intentionally addressed and failing to do so can contrarily worsen disparities. The University of North Carolina (UNC) Internal Medicine clinic at Panther Creek in Cary, NC has found that our Hispanic, Latinx, and Spanish-speaking (HLS) patients have worse diabetes control as measured by HbA1c. As such, the aim of this ongoing QI project is to decrease the gap in HbA1c between HLS and non-HLS patients while addressing the implicated barriers to care.
Methods
Our approach involves identifying barriers to care which lead to disparities in diabetes control, implementing interventions to specifically target these underlying barriers, and monitoring trends in HbA1c. We first interviewed patients, providers, and care partners as part of our baseline assessment of needs. We then focused on improving rates of screening for social determinants of health (SDOH) by adding a prompting phrase in patient appointment notes for overdue SDOH screens as well as holding one-on-one feedback meetings with providers. We are currently implementing a provider-facing low-cost medication guide to target cost of care. Our next planned intervention is to implement a process guide for UNC's Financial Assistance and Pharmacy Assistance programs, and future potential interventions include holding patient-centered group sessions, establishing a food collection resource for the clinic, and distributing transportation vouchers. We are concurrently running and saving data reports every 2 weeks for periodic analyses.
Results
The most prominent barrier reported by providers and care partners is the resource constraints of our clinic; there is only one Spanish-speaking provider and care partner, and certain resources ranging from case management to diabetic exams are only available at the sister clinic in Chapel Hill, NC. Barriers reported by patients included medication affordability, difficulty with Financial Assistance and Pharmacy Assistance applications, lack of accessible transportation, food insecurity, and limited community support. We found that 36 of the 53 HLS patients with diabetes at the clinic were due for SDOH screening; after implementing one-on-one provider meetings and prompting notes in the schedule, 13 HLS patients were screened of which 8 screened positive. The most prevalent risk was finances, followed by housing, food, and transportation. No changes in HbA1c have been noted thus far.
Conclusion
We identified significant disparities amongst our patient population with multiple contributing drivers, many of which intersect. Notable factors include the absence of on-site resources and difficulties navigating the healthcare system. The barriers to HbA1c control are also implicated in other diabetes-related outcomes such as maintenance exams and access to medications. We are focusing on creating tangible resources to ensure that our interventions are both sustainable and adoptable by other clinics. Although the outcome measure for our project assesses HbA1c, process measures will help track the utility of each intervention.
References
- Lion KC, Faro EZ, Coker TR. All quality improvement is health equity work: designing improvement to reduce disparities. Pediatrics. 2022;149:e2020045948E. [PMID: 35230431] doi:10.1542/peds.2020-045948E
- Schneider EC, Chin MH, Graham GN, et al. Increasing equity while improving the quality of care: JACC focus seminar 9/9. J Am Coll Cardiol. 2021;78:2599-2611. [PMID: 34887146] doi:10.1016/j.jacc.2021.06.057
- Fortmann AL, Savin KL, Clark TL, et al. Innovative diabetes interventions in the U.S. hispanic population. Diabetes Spectr. 2019;32:295-301. [PMID: 31798285] doi:10.2337/ds19-0006
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