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Cultural Competency Training and Performance Reports to Improve Diabetes Care for Black Patients: A Cluster Randomized, Controlled Trial

Thomas D. Sequist, MD, MPH; Garrett M. Fitzmaurice, ScD; Richard Marshall, MD; Shimon Shaykevich, MS; Amy Marston, BA; Dana Gelb Safran, ScD; and John Z. Ayanian, MD, MPP
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Vanguard Medical Associates, Harvard Medical School, Tufts Medical Center, and Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts.

Acknowledgment: The authors thank the patients and physicians of Harvard Vanguard Medical Associates for their participation in this study.

Grant Support: By the Robert Wood Johnson Foundation.

Potential Conflicts of Interest:Consultancies: T.D. Sequist (Aetna).

Requests for Single Reprints: Thomas D. Sequist, MD, MPH, Brigham and Women's Hospital, Division of General Medicine, 1620 Tremont Street, Boston, MA 02120; e-mail, tsequist@partners.org.

Current Author Addresses: Drs. Sequist and Fitzmaurice and Mr. Shaykevich: Brigham and Women's Hospital, Division of General Medicine, 1620 Tremont Street, Boston, MA 02120.

Dr. Marshall and Ms. Marston: Harvard Vanguard Medical Associates, Office of Clinical Research, 133 Brookline Avenue, Boston, MA 02215.

Dr. Safran: Blue Cross Blue Shield of Massachusetts, Landmark Center, 401 Park Drive, Boston, MA 02215.

Dr. Ayanian: Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115.

Author Contributions: Conception and design: T.D. Sequist, G.M. Fitzmaurice, R. Marshall, D.G. Safran, J.Z. Ayanian.

Analysis and interpretation of the data: T.D. Sequist, G.M. Fitzmaurice, R. Marshall, S. Shaykevich, A. Marston, D.G. Safran, J.Z. Ayanian.

Drafting of the article: T.D. Sequist, G.M. Fitzmaurice, A. Marston.

Critical revision of the article for important intellectual content: T.D. Sequist, G.M. Fitzmaurice, R. Marshall, S. Shaykevich, D.G. Safran, J.Z. Ayanian.

Final approval of the article: T.D. Sequist, G.M. Fitzmaurice, R. Marshall, D.G. Safran, J.Z. Ayanian.

Provision of study materials or patients: T.D. Sequist, R. Marshall.

Statistical expertise: T.D. Sequist, G.M. Fitzmaurice, S. Shaykevich.

Obtaining of funding: T.D. Sequist, R. Marshall, D.G. Safran.

Administrative, technical, or logistic support: T.D. Sequist, R. Marshall, A. Marston.

Collection and assembly of data: T.D. Sequist, A. Marston.

Ann Intern Med. 2010;152(1):40-46. doi:10.7326/0003-4819-152-1-201001050-00009
Text Size: A A A

Background: Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients.

Objective: To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients.

Design: Cluster randomized, controlled trial conducted between June 2007 and May 2008. (ClinicalTrials.gov registration number: NCT00436176)

Setting: 8 ambulatory health centers in eastern Massachusetts.

Participants: 124 primary care clinicians caring for 2699 (36%) black and 4858 (64%) white diabetic patients.

Intervention: Intervention clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A1c (HbA1c) and low-density lipoprotein (LDL) cholesterol levels and blood pressure.

Measurements: Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months.

Results: White and black patients differed significantly in baseline rates of achieving an HbA1c level less than 7% (46% vs. 40%), an LDL cholesterol level less than 2.59 mmol/L (<100 mg/dL) (55% vs. 43%), and blood pressure less than 130/80 mm Hg (32% vs. 24%) (all P < 0.050). At study completion, intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole (82% vs. 59%; P = 0.003), within their local health center (70% vs. 51%; P = 0.020), and among their own patients (63% vs. 43%; P = 0.037). Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA1c level (48% vs. 45%; P = 0.24), LDL cholesterol level (48% vs. 49%; P = 0.40), or blood pressure (23% vs. 25%; P = 0.47).

Limitation: 11% of primary care teams did not attend cultural competency training sessions.

Conclusion: The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.

Primary Funding Source: Robert Wood Johnson Foundation.


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Appendix Figure 1.
Racial differences in reported needs for self-management support.

We asked our patients whether they needed more help from their health care team to keep their diabetes under good control and identified significant differences according to patient race.

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Appendix Figure 2.
Sample physician-level clinical performance feedback report.

The Black-White Difference (Trend) graphs included data only for patients in the clinician's own panel. Negative numbers in the trend graphs indicate worse outcomes for black patients than for white patients. HbA1c = hemoglobin A1c; LDL = low-density lipoprotein.

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Figure 1.
Study flow diagram.

NP = nurse practitioner; PA = physician assistant.

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Submit a Comment/Letter
Re:Cultural Competency Training and Performance Reports to Improve Diabetes Care for Black Patients: A Cluster Randomized, Controlled Trial
Posted on February 23, 2010
Thomas D. Sequist
No Affiliation
Conflict of Interest: None Declared

We appreciate the comments submitted by Wallace, and agree that increasing physician workforce diversity is an important goal to improve care for minority patients (1). This goal represents a form of organizational cultural competence that may broadly improve the health care experience of minority patients (2). However, long-term efforts to improve the diversity of the health care workforce must be accompanied by targeted efforts involving the current workforce. Our quality improvement program that combined cultural competency training and performance feedback raised clinicians' awareness of racial disparities in care. This awareness is a necessary first step to engage clinicians in efforts to eliminate racial disparities in care. Our data highlight, however, that improving patients' outcomes will require more than raising clinicians' consciousness and highlighting performance gaps. Effective solutions to the problem of racial disparities will require more effective collaboration among all members of health care delivery teams and the communities they serve.

Regarding the comments of Pogach, our own recent analyses suggest that intermediate outcomes of diabetes care, including glycemic, cholesterol, and blood pressure control can be reliably measured at the physician level based on currently accepted standards (3). However, it is important to stress that we were not using physician-level data for high- stakes purposes such as public reporting or pay for performance, but rather as an educational tool for internal quality improvement, lessening the need for strict reliability.

We recognize that there is ongoing debate regarding the most appropriate targets for diabetes care (4). Our clinical trial was implemented prior to the publication of much of these data, and we were focused on achieving the clinical targets being promoted by the delivery organization at the time when our intervention took place. As suggested by Pogach, we analyzed our outcomes using less stringent clinical treatment goals (HbA1c<8.0%, LDL<130 mg/dL, and BP<140/90 mmHg) and still found that our intervention did not reduce the substantial racial disparities in these measures. We also analyzed additional information beyond the achievement of clinical targets, including the use of statins, and found that racial disparities in the use of these effective medicines persisted despite our intervention.

Our study provides important lessons regarding systematic quality improvement focused on minority patients. As future solutions are sought to the persistent challenge of racial disparities in quality of care, ensuring that care is individualized to meet the specific needs of each patient may be the most effective approach to achieve optimal outcomes.


1. Sequist TD. (Association of American Medical Colleges). Addressing Racial Disparities in Health Care: A Targeted Action Plan for Academic Medical Centers. 2010.

2. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O, 2nd. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293-302.

3. Sequist TD, Schneider EC, Li A, Rogers WH, Safran DG. Reliability of medical group and physician performance measurement in the primary care setting. Med Care. 2010. In press.

4. Krumholz HM, Lee TH. Redefining quality--implications of recent clinical trials. N Engl J Med. 2008;358:2537-9.

Conflict of Interest:

None declared

Submit a Comment/Letter

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