Quality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands

Joshua J. Fenton; Michael Von Korff; Elizabeth H.B. Lin; Paul Ciechanowski; Bessie A. Young

doi:10.1370/afm.421

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Figure 1.
Receipt of diabetes preventive services by patterns of use.

HbA_1C = hemoblogin A_1C.

Note: Values are rates of receipt of services over a 2-year period. Microalbuminuria screening was assessed only in patients who did not have a prescription for an angiotension-converting enzyme inhibitor at baseline. Comparison of outcomes across use patterns are statistically significant (P <.001), except for the comparison of microalbuminuria screening (P = .05).

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Table 1.

Social, Demographic, and Clinical Characteristics of Patients by Pattern of Use of Outpatient Services

		Pattern of Use*
Characteristic^†	Total Sample (N = 4,463)	Infrequent (n = 1,576)	Lower-Priority (n = 542)	Higher-Priority (n = 2,345)
HbA_1c = hemoglobin A_1c; BMI = body mass index.
* Infrequent users were 35.3% of the total sample; lower-priority users, 12.1%; and higher-priority users, 52.5%.
† Sample size may vary because of missing data. All comparisons across use patterns are statistically significant (P <.001), except for the comparison for race (P = .28).
Women, No. (%)	2,175 (48.7)	663 (42.1)	321 (59.2)	1,191 (50.1)
High school education or less, No. (%)	1,088 (24.7)	345 (22.1)	115 (21.4)	628 (27.1)
Marital status, No. (%)
Single	431 (10.0)	177 (11.3)	48 (8.9)	206 (8.9)
Married/living as	2,925 (66.0)	1,077 (68.8)	348 (64.6)	1,500 (64.5)
Widowed	547 (12.4)	132 (8.4)	72 (13.4)	343 (14.8)
Divorced or separated	526 (11.8)	179 (11.4)	71 (13.2)	276 (11.9)
Nonwhite race, No. (%)	892 (20.4)	334 (37.4)	111 (12.4)	447 (50.1)
Age, y, mean (SD)	64.9 (12.6)	60.1 (12.7)	61.5 (13.7)	65.8 (13.2)
RxRisk comorbidity score, No. (%)
<1,300	915 (20.5)	527 (33.4)	118 (21.8)	270 (11.5)
1,300–2,599	1,147 (25.7)	506 (32.1)	145 (26.8)	496 (21.2)
2,600–4,399	1,178 (26.4)	387 (24.6)	157 (29.0)	634 (27.0)
≥ 4,400	1,223 (27.4)	156 (9.9)	122 (22.5)	945 (40.3)
Diabetes complications, No. (%)
0	1,404 (31.4)	774 (49.1)	183 (33.8)	447 (19.1)
1	1,405 (31.5)	549 (34.8)	199 (36.7)	657 (28.0)
2	853 (19.1)	187 (11.9)	112 (20.7)	554 (23.6)
≥ 3	801 (17.9)	66 (4.2)	48 (8.9)	687 (29.3)
HbA_1C ≥ 8.0%, No. (%)	1,982 (46.3)	682 (46.5)	197 (38.0)	1,103 (48.2)
Treatment intensity, No. (%)
None or diet	1,134 (25.4)	462 (29.3)	188 (34.7)	484 (20.6)
Oral hypoglycemic agent	1,986 (44.5)	790 (50.1)	252 (46.5)	944 (40.3)
Insulin ± oral hypoglycemic	1,343 (30.1)	324 (20.6)	102 (18.8)	917 (39.1)
BMI ≥ 30 kg/m², No. (%)	2,147 (48.8)	727 (46.8)	308 (58.0)	1,112 (48.2)
Smoking currently, No. (%)	381 (8.6)	184 (11.8)	44 (8.3)	153 (6.7)
Depression status, No. (%)
Not depressed	3,552 (79.5)	1,344 (85.3)	410 (75.7)	1,798 (76.7)
Minor depression	375 (8.4)	108 (6.9)	47 (8.7)	220 (9.4)
Major depression	536 (12.0)	124 (7.9)	85 (15.7)	327 (13.9)

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Table 2.

Outpatient Visits During the 2-Year Study Period by Pattern of Use

		Pattern of Use
Type of Visit*	Total Sample (N = 4,463)	Infrequent (n = 1,576)	Lower-Priority (n = 542)	Higher-Priority (n = 2,345)
* Values are mean (SD) numbers of visits. Excludes visits for dermatologic diagnoses, vision and hearing, mental health illness, and preventive and pregnancy-related services. All comparisons across use patterns are statistically significant (P <.001).
Acute disease—higher priority	1.9 (2.7)	0.5 (0.8)	1.9 (1.9)	2.8 (3.2)
Acute disease—lower priority	1.3 (1.8)	0.5 (0.8)	3.2 (2.7)	1.4 (1.6)
Chronic disease—higher priority	7.5 (7.4)	3.0 (1.6)	4.8 (3.1)	11.2 (8.4)
Chronic disease—lower priority	1.3 (1.9)	0.3 (0.6)	3.1 (2.8)	1.5 (1.9)
Symptoms and ill-defined conditions	1.6 (2.4)	0.4 (0.7)	4.2 (4.2)	1.8 (2.0)
Total	13.6 (11.2)	4.8 (2.0)	17.3 (9.4)	18.7 (11.5)

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Table 3.

Adjusted Odds of Timely Receipt of Diabetes-Related Preventive Services by Pattern of Use

	Pattern of Use*
Diabetes-Related Preventive Service	Infrequent OR (95% CI)^†	Lower-Priority OR (95% CI)^†	Higher-Priority OR (95% CI)^†
OR = odds ratio; CI = confidence interval; HbA_1C = hemoglobin A_1C; ref = reference group.
* Includes fewer patients than bivariate analyses because of missing data.
† Odds ratios adjusted for age, sex, marital status, ethnicity, education, comorbidity (RxRisk score), number of diabetes complications, treatment intensity, depression status, and clinic site.
‡ Among patients not prescribed an angiotensin-converting enzyme inhibitor.
≥ 1 HbA_1C test in previous year (n = 4,347)	0.35 (0.24–0.51)	0.59 (0.35–1.01)	ref
≥ 3 HbA_1C tests in previous year if HbA_1C ≥ 8% (n = 1,837)	0.44 (0.35–0.56)	0.80 (0.57–1.12)	ref
≥ 1 retinal examinations in previous year (n = 4,347)	0.74 (0.63–0.86)	0.68 (0.56–0.84)	ref
≥ 2 retinal examinations in 2 previous years if known retinopathy (n = 1,179)	0.57 (0.40–0.81)	0.55 (0.34–0.89)	ref
≥ 1 microalbuminuria screenings in previous year (n = 1,831)^‡	0.75 (0.58–0.96)	0.79 (0.57–1.09)	ref

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The Article in Brief

Quality of preventive care for diabetes: effects of visit frequency and competing demands

Joshua J. Fenton, MD, MPH , and colleagues

Background Regular medical care can prevent many common diabetes complications. Despite the effectiveness of preventive care for diabetes, however, many patients do not receive recommended diabetes services. This study examined how often a group of diabetes patients visited the doctor, and for what reasons, in order to shed light on why some patients do not receive sufficient diabetes care.

What This Study Found Diabetes patients who do not visit the doctor often are less likely to receive timely diabetes-related preventive care. Patients who make frequent doctor visits but for lower-priority health conditions are more likely to have a delay in their diabetes-related preventive services.

Implications

Office systems and other innovations may help primary care offices increase the delivery of diabetes services to patients who don�t visit the doctor often, and to those who visit for conditions that a