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

Background Diabetes is one of the most widespread chronic condition. If its complications are not prevented, diabetes is potentially disabling for patients and costly for healthcare systems. An effective management of diabetes care, addressing also patients’ socio-economic conditions, has to be realized. Several strategies can be settled to reduce the impact of inequalities in diabetes care. A systematic review was performed to determine whether implementation of clinical care strategies in managed care is related to a reduction of inequalities in diabetes care. Methods A systematic review was carried out by quering electronic databases using the key-words ‘‘management’’, ‘‘diabetes’’, [‘‘disparities’’ or ‘‘inequalities’’], combined with Boolean operators. Furthermore, a snowball search was performed to enlarge the number of articles. A quality assessment was conducted too. All the studies concerning a specific evaluation of strategies adopted in diabetes managed care to reduce socio-economic disparities were selected. A data extraction form was designed to record key information for each study: authors, journal, year of publication, country, study sample, study design, purpose of the study, variables considered, disparities investigated. The attenuation in disparities was analyzed pointing out the change in outcomes or outputs grouped in different macro-areas. Results Out of 8408, six studies met the inclusion criteria. The selected studies were published between 2006 and 2011 in USA and Netherlands. Total sample regarded 54 454 people. Although the setting was different for each study, in all of them a specific strategy of managed care was applied to address socioeconomic disparities. Investigated disparities were sociodemographic variables, race/ethnicity, geographic location. Four studies analyzed seven outcomes, whereas five studies investigated 14 outputs. The most studied output (four studies) was the frequency of HbA1c testing and it was not observed an uniform result among the four studies. Conclusion Despite of remarkable investments of managed care programs in underserved population, the role of specific strategies in diabetes care to reduce disparities leads to very heterogeneous results, with differences regarding to the type of indicator used (outcomes or outputs). Key message This review contributes to the debate about disparities in healthcare through the evaluation of the impact of managed care strategies to reduce socio-economic disparities among diabetes patients.