Inequalities in diabetes managed care: a systematic review of the literature

Background\r\nDiabetes is one of the most widespread chronic condition. If\r\nits complications are not prevented, diabetes is potentially\r\ndisabling for patients and costly for healthcare systems. An\r\neffective management of diabetes care, addressing also patients’\r\nsocio-economic conditions, has to be realized. Several\r\nstrategies can be settled to reduce the impact of inequalities\r\nin diabetes care. A systematic review was performed to determine whether implementation of clinical care strategies in\r\nmanaged care is related to a reduction of inequalities in\r\ndiabetes care.\r\nMethods\r\nA systematic review was carried out by quering electronic\r\ndatabases using the key-words ‘‘management’’, ‘‘diabetes’’,\r\n[‘‘disparities’’ or ‘‘inequalities’’], combined with Boolean\r\noperators. Furthermore, a snowball search was performed to\r\nenlarge the number of articles. A quality assessment was\r\nconducted too. All the studies concerning a specific evaluation\r\nof strategies adopted in diabetes managed care to reduce\r\nsocio-economic disparities were selected. A data extraction\r\nform was designed to record key information for each study:\r\nauthors, journal, year of publication, country, study sample,\r\nstudy design, purpose of the study, variables considered,\r\ndisparities investigated. The attenuation in disparities was\r\nanalyzed pointing out the change in outcomes or outputs\r\ngrouped in different macro-areas.\r\nResults\r\nOut of 8408, six studies met the inclusion criteria. The selected\r\nstudies were published between 2006 and 2011 in USA and\r\nNetherlands. Total sample regarded 54 454 people. Although\r\nthe setting was different for each study, in all of them a specific\r\nstrategy of managed care was applied to address socioeconomic\r\ndisparities. Investigated disparities were sociodemographic\r\nvariables, race/ethnicity, geographic location.\r\nFour studies analyzed seven outcomes, whereas five studies\r\ninvestigated 14 outputs. The most studied output (four\r\nstudies) was the frequency of HbA1c testing and it was not\r\nobserved an uniform result among the four studies.\r\nConclusion\r\nDespite of remarkable investments of managed care programs\r\nin underserved population, the role of specific strategies in\r\ndiabetes care to reduce disparities leads to very heterogeneous\r\nresults, with differences regarding to the type of indicator used\r\n(outcomes or outputs).\r\nKey message\r\n This review contributes to the debate about disparities in\r\nhealthcare through the evaluation of the impact of managed\r\ncare strategies to reduce socio-economic disparities among\r\ndiabetes patients.