Dissertation Title： "Evaluating Racial Differences in Quality of Diabetes Care and Self-Management Practice in an HMO"Racial disparities in health care continue to be a growing problem in the U.S. and a prominent health policy issue. This dissertation focuses on the determinants of racial disparities in diabetes health care and methods for addressing these issues. Previous studies show that black diabetes patients are at greater risk for adverse health events than white diabetes patients, but they may be less likely to gain access to important clinical innovations or to adhere to complex diabetes care regimens.

The first study evaluates the differential impact of a quality of care improvement, investigating whether the effect of a widely mandated policy providing coverage of self-management technologies for all diabetes patients helped to reduce race-related barriers to glucose self-monitoring. While this study found that the policy was effective in motivating diabetes patients on hypoglycemic therapy to begin to self-monitor, black patients were less likely to sustain monitoring. This finding led to subsequent studies evaluating racial differences in long-term adherence to self-management practices among diabetes patients within the same HMO setting. These longitudinal studies focus on the effect of race and adherence to two main diabetes self-management constructs: glucose self-monitoring (study 2) and medication use (study 3).

In the second study we used a well-established standard of self-monitoring to evaluate race differences in long-term glucose self-monitoring among newly drug-treated diabetes patients in an HMO. Findings showed that racial differences in self-monitoring persisted over time, with blacks less likely to initiate self-monitoring, engage in intensive self-monitoring, and adhere to recommended standards of long-term self-monitoring compared to whites.

In the third study, we used a novel approach to measure medication adherence, linking prescribing and pharmacy claims data to assess race differences in long-term adherence to hypoglycemic monotherapy in a fully insured, newly diagnosed diabetes population. Despite having equal access to services and quality of care, blacks were more likely to discontinue use of hypoglycemic therapy within six months of initiating treatment, and less adherent to long-term drug therapy than whites. These studies' findings suggest that early and continued emphasis in self-management practice, particularly for black patients, may be necessary to reduce persistent racial differences in self-management practice and clinical outcomes.