Do quality improvement initiatives for diabetes care address social inequities? Secondary analysis of a systematic review

Abstract

BackgroundSocially disadvantaged populations carry a disproportionate burden of diabetes-related morbidity and mortality. There is an emerging interest in quality improvement (QI) strategies in the care of patients with diabetes, however, the effect of these interventions on disadvantaged groups remains unclear.ObjectiveThis is a secondary analysis of a systematic review that seeks to examine the extent of equity considerations in diabetes QI studies, specifically quantifying the proportion of studies that target interventions toward disadvantaged populations and conduct analyses on the impact of interventions on disadvantaged groups.Research design and methodsStudies were identified using Medline, HealthStar and the Cochrane Effective Practice and Organisation of Care database. Randomised controlled trials assessing 12 QI strategies targeting health systems, healthcare professionals and/or patients for the management of adult outpatients with diabetes were eligible. The place of residence, race/ethnicity/culture/language, occupational status, gender/sexual identity, religious affiliations, education level, socioeconomic status, social capital, plus age, disability, sexual preferences and relationships (PROGRESS-Plus) framework was used to identify trials that focused on disadvantaged patient populations, to examine the types of equity-relevant factors that are being considered and to explore temporal trends in equity-relevant diabetes QI trials.ResultsOf the 278 trials that met the inclusion criteria, 95 trials had equity-relevant considerations. These include 64 targeted trials that focused on a disadvantaged population with the aim to improve the health status of that population and 31 general trials that undertook subgroup analyses to assess the extent to which their interventions may have had differential impacts on disadvantaged subgroups. Trials predominantly focused on race/ethnicity, socioeconomic status and place of residence as potential factors for disadvantage in patients receiving diabetes care.ConclusionsLess than one-third of diabetes QI trials included equity-relevant considerations, limiting the relevance and applicability of their data to disadvantaged populations. There is a need for better data collection, reporting, analysis and interventions on the social determinants of health that may influence the health outcomes of patients with diabetes.PROSPERO registration numberCRD42013005165.

Undiagnosed type 2 diabetes during pregnancy is associated with increased perinatal mortality: a large population‐based cohort study in Ontario, Canada

“…Also, many of them had chronic hypertension, which should alert caregivers to the increased risk of diabetes [22]. People of a lower socioeconomic status frequently experience a delay in their diabetes diagnosis and receive a lower level of care [21]. The women in our study with undiagnosed type 2 diabetes were also more likely to be immigrants compared with those with diagnosed pre-pregnancy diabetes.…”

“…Our study found that more women with undiagnosed type 2 diabetes were in the lowest socio-economic quintile than any other group, including those previously diagnosed with pre-existing diabetes. It is known that people of lower socioeconomic status are more likely to have higher rates of diabetes [21]. The women in our study with undiagnosed type 2 diabetes were just as likely to have a primary care physician and also had more visits to their primary care physician prior to pregnancy then those with GDM alone, and therefore this represents missed opportunities for a diabetes diagnosis pre-pregnancy.…”

Socio‐economic status and mortality in people with type 1 diabetes in Scotland 2006–2015: a retrospective cohort study

“…However, their benefits may be more apparent in higher SES groups who possess the resources to facilitate their use [26]. A recent systematic review found that fewer than one-third of quality improvement trials included equity-relevant considerations, limiting their application to disadvantaged groups [27]. Ensuring that quality improvement initiatives consider their effects across socio-economic groups will help to ensure interventions are appropriate and will not inadvertently exacerbate inequalities.…”

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