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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Visit behavior may reflect self-care abilities
Understanding competing demands: co-morbidities need to be explored
Next steps in transforming diabetes care
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Elizabeth A. Bayliss, Denver, CO Family physician, Clinician Researcher
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In their article, Quality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands, Fenton et al. discuss measures of diabetes care as a function of number and type of visit frequency.(1) The authors hypothesize that “infrequent” or “lower priority” outpatient visits will result in decreased diabetes preventive care. The assumption underlying these hypotheses (mine, not stated by the authors) is that receipt of diabetes preventive care is in some way a function of the outpatient office visit. This assumption prompts two questions: Are type and number of visits actually proxies for something else? And, is there anything about receipt of diabetes preventive care that requires an outpatient visit? Diabetes preventive care largely consists of chronic disease self- care which is defined as follows: Engaging in activities that promote physical and psychological health; interacting with health care providers and adherence to treatment recommendations; monitoring health status and making associated care decisions; and managing the impact of the illness on physical, psychological and social functioning.(2) Patient-initiated visit behavior may reflect patients’ relative abilities or inabilities to perform adequate self-care. “Low priority” users have difficulty monitoring health status and making associated care decisions (e.g. appropriate triage of low priority conditions), and “infrequent users” have low levels of interaction with health care providers. It would be interesting to assess, in these sub-populations, levels of patient activation and other factors that are known to influence successful chronic disease self-care. The authors comment that providers’ competing demands during the office visit for lower priority conditions may detract from recommending diabetes preventive care. However, subjects in this investigation that had equal numbers of office visits with ‘higher priority’ concerns could have presented their providers with just as many competing demands. I would suggest that both the patient and the provider have their own set of ‘competing demands’ and that these are likely not the same. I agree with the authors that innovations in care delivery are required to deliver adequate diabetes preventive care. Patients’ priorities will often differ from objective societal priorities, and patients’ and providers will inevitably have (varying) competing demands. All of these priorities and agendas are important and many of them will need to be addressed face to face in the office visit. However scheduling hemoglobin a1c tests and retinal screening do not. Interventions to improve diabetes preventive care need to be two-fold and include both efforts to facilitate improved self-care, combined with systems to remind and contact patients, and track specific preventive services outside of the office visit. (1) Fenton JJ, vonKorff M, Lin EHB, Ciechanowski P, Young BA. Quality of preventive care for diabetes: effects of visit frequency and competing demands. Ann Fam Med 2006;4:32-39 (2) Clark NM, Becker MH, Janz NK, Lorig KR, Rakowski W, Anderson L. Self-management of chronic disease by older adults: A review and questions for research. Journal of Aging Health 1991; 3:3-27. Competing interests: None declared |
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Joseph W LeMaster, Columbia, MO USA Asst. Professor, Department of Family and Community Medicine
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Investigating how competing demands affect delivery of diabetes preventive services and self-care is a complex undertaking. Three articles in this issue of the Annals address the role of competing demands on diabetes preventive service delivery or self-care. Parchman et. al. used direct observation of patient visits and found that patients presenting for acute versus chronic illnesses less frequently received indicated preventive services (e.g. HbA1c testing) during the visit, suggesting that symptomatic complaints distracted the physician and patient from discussing less urgent diabetes prevention.1 Although the investigators controlled for the number of co-morbid conditions, they did not explore the possibility that certain co-morbidities may have been more distracting than others. Fenton et. al., who also report in this issue, examined a large cohort over multiple clinic visits. They found that patients whose main visit diagnosis was coded as a “low-priority” condition or a symptom were less likely to receive diabetes preventive care, i.e. that physicians were distracted from providing such care because the treatment for the condition was less clear.2 While those investigators used a more complex strategy to control for co-morbidity (the RxRisk score), they did not investigate how specific co-morbidities affected care. In the study by Lin et. al, participants randomized to depression care did not improve diabetes self-care or medication compliance.3 Certain combinations of co- morbidities may interact differently to affect health outcomes,4,5 suggesting that adjusting for co-morbidity is very complex. Fried has suggested that investigation of the interaction of the specific co-morbid diseases on health or process outcomes may be more enlightening than adjusting for their joint effects.4 As Lin et. al. suggest, the effect of competing demands on diabetic preventive care may best be clarified by large prospective clinical trials that use an individually-tailored approach that specifically targets each patient’s needs. Further research is urgently needed on this topic. Bibliography 1. Parchman ML, Romero RL, Pugh JA. Encounters by patients with type 2 diabetes--complex and demanding: an observational study. Ann Fam Med 2006; 4(1):40-45. 2. Fenton JJ, Von Korff M, Lin EHB, Ciechanowski P, Young BA. Quality of preventive care for diabetes: effects of visit frequency and competing demands. Ann Fam Med 2006; 4(1):32-39. 3. Lin EHB, Katon W, Rutter C, Simon GE, Ludman EJ, Von Korff M, et al. Effects of enhanced depression treatment on diabetes self-care. Ann Fam Med 2006; 4(1):46-53. 4. Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: the Women's Health and Aging Study. J Clin Epidemiol 1999;52(1):27-37. 5. Volpato S, Blaum C, Resnick H, Ferrucci L, Fried LP, Guralnik JM, et al. Comorbidities and impairments explaining the association between diabetes and lower extremity disability: The Women's Health and Aging Study. Diabetes Care 2002;25(4):678-683. Competing interests: None declared |
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Richard W Grant, Boston, MA Research Physician, General Medicine Unit, Massachusetts General Hospital and Harvard Medical School
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In theory, preventive care for patients with diabetes is so simple – order a blood test or two, vaccinate, look at the feet and refer for retinal exam – it boggles the mind that all patients with diabetes do not routinely receive all such services each year. The very simplicity of the required tasks, however, suggests that system-level barriers rather than inadequate physician education or training underlie the gap between ideal and actual care. With this insight, it is clear that efforts to overcome barriers to effective diabetes management must first delve into the fine details of actual care. This current issue of Annals of Family Medicine presents a series of reports that focus on such details of care. Among these studies, the paper by Fenton et al takes an innovative analytic approach to understanding why patients fall short of preventive goals. Although it really only takes a single visit to perform all required actions for preventive services, Fenton et al found that patients and doctors have to cross paths multiple times over the course of a year to ensure that all goals get met. The real insight from this paper is that it’s not just the quantity but also the quality of the visits that matter. That is, patients with frequent visits for low priority problems are less likely to receive preventive services that have been shown over the long run to have the greatest impact on overall health. This distinction provides quantitative evidence for the role of competing demands in hindering effective diabetes care. Parchman et al take a direct observational approach to “look under the hood” of the care interaction. This study confirms the role of competing demands in sidetracking the goals of diabetes care. Given enough time during a visit focused on chronic disease management, patients tend to receive high quality care. So what are the innovative models and new approaches to change care? Other studies have confirmed the powerful role of a good patient-doctor relationship that has been developed over time and is characterized by good communication. Rather than “carving out” diabetes-related services to be taken care of by specialists and their support staff, perhaps the next step is to give primary care doctors and their patients enough time during a set-aside visit to focus specifically on diabetes management goals each year. Such a change would require a system for tracking patients with diabetes, scheduling diabetes visits, and a reimbursement mechanism that would remove the “time crunch” experienced by providers during their hectic workday. Competing interests: None declared |
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