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1 VERDICT Health Services Research Center, South Texas Veterans Health Care System, San Antonio, Tex
2 Department of Family & Community Medicine, University of Texas Health Science Center-San Antonio, San Antonio, Tex
3 Department of Medicine, University of Texas Health Science Center-San Antonio, San Antonio, Tex
CORRESPONDING AUTHOR: Michael L. Parchman, MD, MPH, South Texas Veterans Health Care System, VERDICT 11C6, 7400 Merton Minter Blvd, San Antonio, TX 78229-4404, parchman{at}uthscsa.edu
PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A1c) level.
METHODS We observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A1c values and dates were determined from the chart.
RESULTS Among patients with an A1c level greater than 7%, each additional patient concern was associated with a 49% (95% confidence interval, 35%–60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A1c. Among patients with an A1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A1c level, the time to the next scheduled appointment decreased by 8.6 days (P=.001).
CONCLUSIONS The concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings.
Key Words: Diabetes mellitus, type 2 • hemoglobin A, glycosylated • ambulatory care • primary care • health care delivery • health services research • quality of care • practice-based research networks • office visits
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