Quality Improvement Efforts Provide Mixed Results on Race and Sex Differences in Health Outcomes Among Hemodialysis Patients

CHICAGO - Quality improvement methods are promising, but in their current form are insufficient to eliminate health disparities among hemodialysis patients, according to a study in the February 26 issue of the Journal of the American Medical Association (JAMA).

Ashwini R. Sehgal, M.D., associate professor of medicine at Case Western Reserve University School of Medicine and the MetroHealth Medical Center, Cleveland, writes that race and sex disparities in health outcomes have been extensively documented, but that little is known about the actual impact of quality improvement activities on reducing health disparities. Sehgal’s study objective was to determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. Hemodialysis is a process used in patients with kidney failure to purify the blood through filtration using dialysis machines.

Sehgal evaluated data from 58,700 hemodialysis patients who were randomly selected between 1993 through 2000 as part of the Centers for Medicare and Medicaid Services quality improvement project. Sehgal analyzed the data looking at changes in hemodialysis dose (kt/V), anemia management (hemoglobin level), and nutritional status (albumin level).

“The proportion of all patients with an adequate hemodialysis dose increased 2-fold,” Sehgal reports. “In 1993, 46 percent of white patients and 36 percent of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87 percent and 84 percent, respectively. Thus, the gap between white and black patients decreased from 10 percent to 3 percent. The gap between female and male patients decreased from 23 percent to 9 percent over the same period.”

Sehgal writes that the proportion of all patients with adequate hemoglobin levels increased 3-fold, from 26 percent in 1993 to 74 percent in 2000. “The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly.”

Sehgal concludes, “Race and sex disparities should be targeted as part of quality improvement activities. Outcomes of whites, blacks, men, and women should be monitored separately, and race- and sex-specific quality improvement methods should be developed when appropriate.”

(JAMA. 2003; 289:996-1000; available post-embargo at jama.com)

Editor’s Note: This study was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases.

EDITORIAL: IMPROVING QUALITY AND REDUCING DISPARITIES

In an accompanying editorial, Kaytura Felix Aaron, M.D., and Carolyn M. Clancy, M.D., from the Agency for Healthcare Research and Quality, Rockville, Md., write that Sehgal “addresses a crucial question in his study: Can efforts to improve quality of care for dialysis patients simultaneously reduce disparities in care associated with race and ethnicity?”

“As the findings by Sehgal show, a generic quality improvement may concurrently reduce racial/ethnic disparities in care, but results may be inconsistent. Appropriate collection and use of racial and ethnic data are essential to evaluate progress in minimizing inequality in quality of care,” Aaron and Clancy write.

“The rising tide of quality improvement may lead to improvements for all patients. But failure to examine the distribution of benefits may also wash away undiscovered information about the intersections of disease, individual characteristics, and health care delivery that are essential for eliminating disparities in health care and continuing to develop effective treatments.”

(JAMA. 2003; 289; 1033-1034; available at jama.com)

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