Diabetes Preventive Services and Policy Implications in the U.S.

OBJECTIVE

To investigate whether the patient or physician practice characteristics predict the use of diabetes preventive care services.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of a nationally representative sample of 27,169 adult ambulatory care visits, using the 2007 National Ambulatory Medical Care Survey data. The outcome variable is whether any preventive care services, defined as diagnostic tests (glucose, urinalysis, A1C, and blood pressure) or patient education (diet/nutrition, exercise, and stress management), were ordered/provided. Multivariate analysis was performed to identify independent predictors of diabetes preventive care services, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design and analytic weights.

RESULTS

Compared with people without diabetes, diabetic patients were older (63 vs. 53 years; P < 0.01) and were more likely to be nonwhite and covered by Medicare insurance. In multivariate analyses, younger patients and the availability of primary care physicians, electronic medical records, and on-site laboratory tests were associated with more effective preventive care services (P < 0.05). If physician compensation relied on productivity, preventive care services were less likely (odds ratio 0.4 [95% CI 0.27–0.82 for men and 0.26–0.81 for women]). Although the patterns of patient education and diagnostic testing were similar, the provision of patient education was less likely than that of diagnostic testing.

CONCLUSIONS

Primary care physicians and practice features seem to steer diabetes preventive services. Given the time constraints of physicians, strategies to strengthen structural capabilities of primary care practices and enhance partnerships with public health systems on diabetic patient education are recommended.Diabetes is a common chronic condition and costly disease that demands effective preventive care services (1). In 2007, an estimated 23.6 million people in the U.S. had diabetes (2). Patients with diabetes have an increased risk of morbidity and mortality from several conditions, such as cardiovascular, cerebrovascular, or kidney diseases and heart failure (3–5). Previous studies have shown that interventions or intensive management of glucose and hypertension are likely to reduce the morbidity and mortality of diabetes-related complications (6,7). In addition, economic analysis indicates that mean total costs associated with microvascular complications have almost doubled compared with those for patients without these complications (1). Thus, both intervention and economic studies suggest the critical importance of providing effective interventions and preventive care services for patients with diabetes. However, underuse of recommended preventive services is reported for people with diabetes (5). Furthermore, it is unclear whether patient or physician practice characteristics predict the use of diabetes preventive services. Given the racial/ethnic differences in mean glucose, diabetes prevalence, and diabetes-related cardiovascular disease (8,9), it is important to identify whether there are disparities in the provision of preventive care services for patients with diabetes.To our knowledge, no previous study has examined the utilization patterns of preventive care services for patients with diabetes in a national sample of adult ambulatory care visits. Therefore, the newly released data from the 2007 National Ambulatory Medical Care Survey (NAMCS) were selected to investigate the use of diabetes preventive services during routine care for preventing the long-term complications of diabetes. The objective of this analysis was to identify whether patient or physician practice characteristics predict the likelihood of diabetes preventive care services.     

Patient satisfaction and use of Veterans Affairs versus non-Veterans Affairs healthcare services by veterans

OBJECTIVES: Chronically ill patients who are not satisfied with their care may change healthcare providers or systems, which could disrupt continuity of care and impede management of their conditions. We examined whether patient satisfaction affected subsequent use of non-Veterans Affairs (VA) services among chronically ill veterans discharged from VA hospitals. METHODS: The data used in this study came from a multicenter trial of increased access to primary care. We enrolled patients with diabetes, heart failure, and/or chronic obstructive pulmonary disease who were discharged from 1 of 9 VA medical centers. At baseline, we assessed satisfaction using the Patient Satisfaction Questionnaire. VA and non-VA utilization over the subsequent 6 months were assessed using VA and Medicare administrative data, non-VA billing data, and patient interviews. Using multivariable logistic regression analyses, we examined whether baseline patient satisfaction was associated with non-VA inpatient or outpatient utilization during the next 6 months. We conducted the same analysis for Medicare-eligible veterans, a group with better access to non-VA care. RESULTS: Of 1375 study patients, 174 (13%) used non-VA healthcare. Patients with non-VA utilization were older and lived farther from a VA. The odds of non-VA use decreased by 11% as satisfaction increased (odds ratio 0.89; 95% confidence interval 0.83-0.97; P = 0.005). This relationship was strongest among Medicare-eligible veterans (odds ratio 0.85; 95% confidence interval 0.77-0.93; P = 0.001). CONCLUSIONS: Dissatisfied veterans discharged from the hospital were more likely to go outside VA for care. Thus, improvements in patient satisfaction may lead to improvements in continuity of care.     

The effects of patient volume on the quality of diabetic care for Medicare beneficiaries

BACKGROUND: The quality of care for Medicare beneficiaries with diabetes remains suboptimal. The contributing factors at the physician level are not well characterized, especially the relationship of patient volume and physician performance. OBJECTIVE: We sought to determine associations between the number of Medicare diabetic patients cared for by a primary care physician and the receipt of important diabetic processes of care. DESIGN: Physicians were grouped into quintiles based on the number of Medicare patients with diabetes. Hierarchical generalized linear models were used to examine associations between number of patients, frequency of visits, physician experience, patient factors and the receipt of diabetes processes of care using Part A and B Medicare claims data for 2001. PARTICIPANTS AND PATIENTS: All Connecticut primary care physicians who cared for Medicare fee-for-service beneficiaries with diabetes in 2001. MAIN OUTCOME MEASURES: The main outcome measures were associations of the receipt of diabetes process of care measures with the number of diabetic Medicare patients in a physician practice panel, adjusted for frequency of visits, patient comorbidity, age, ethnicity, and physician experience. RESULTS: Patients in the highest volume physician quintile were significantly more likely to have received hemoglobin A1c measurements, lipid profiles, and retinal eye examinations than patients in the lowest physician quintile in 2001, even after adjustment for multiple factors. For each step up in quintile volume group among primary care physicians, the increased odds of receiving a hemoglobin A1c measurement was 1.16 (95% confidence interval [CI] 1.10-1.23), 1.12 (95% CI 1.07-1.18) for a lipid profile, 1.06 (95% CI 1.02-1.09) for a retinal eye examination, and 1.48 (95% CI 1.22-1.81) for receiving all 3 measures. CONCLUSIONS: This study suggests that Medicare fee-for-service patients with diabetes cared for by physicians with greater numbers of diabetic Medicare patients in their practice are more likely to receive important diabetes processes of care.     

Rapid Two-stage Emergency Department Intervention for Seniors: Impact on Continuity of Care

OBJECTIVES: A two-stage intervention comprising screening and a brief standardized nursing assessment and referral, for emergency department (ED) patients aged 65 years and over, reduced the rate of functional decline four months after the visit, without increasing societal costs. In this study, the authors investigated the effects of the intervention on the process of care at, and during the month after, the ED visit. METHODS: Patients at four Montreal hospital EDs were randomized by day of visit to the intervention or to usual care. Patients admitted to the hospital were excluded. Measures of process of care included: referrals and visits to the primary physician and to the local community health center, for home care or other services, and return ED visits. Data sources included hospital charts, patient questionnaires, and provincial administrative databases. RESULTS: The study sample included 166 intervention and 179 control group patients ready for discharge from the ED. Intervention group patients were more likely to have a chart-documented referral to their local community health center [adjusted odds ratio (OR) 4.0, 95% confidence interval (95% CI) = 1.7 to 9.5] and their primary physician [adjusted OR 1.9, 95% CI = 1.0 to 3.4], and to have received home care services one month after the ED visit [adjusted OR 2.3, 95% CI = 1.1 to 5.1]. Unexpectedly, they were also more likely to make a return visit to the ED [adjusted OR 1.6, 95% CI = 1.0 to 2.6]. CONCLUSIONS: The beneficial outcomes of the intervention appear to result primarily from the early provision of home care rather than early contact with the primary physician.     

Illness severity and total visits in family medicine

Objective The purpose of this study was to estimate the independent effect of clinical severity on visit utilization by family medicine patients so that disease management programmes can be targeted accurately and immediately towards patients most likely to benefit from them. Design A convenience sample of 698 primary care patients was analysed. All patients had been referred to a medical specialist. Utilization of all types of medical services including laboratory, radiology and ancillary services was used to classify patients as high‐utilizers (the top 20%) or not high‐utilizers. Patients were stratified into three severity categories based on point scores assigned to specific diseases. The diagnoses included in the Charlson severity index were used to score each patient and the Charlson point scores were used to measure severity. The odds of being a high‐utilizer were adjusted for severity category and demographic variables. Results Severity was independently related to the odds of being a high‐user (adjusted odds ratio = 2.7 for severity = 1 and 5.7 for severity = 2, with the reference category being severity = 0). Age was related to high‐use in univariate analyses but not in multivariate analyses. Conclusions Case management programmes in primary care practices should consider using disease severity to identify cases. Severity data can be abstracted by medical secretaries who review narrative problem lists as well as billing codes.     

Is physician gender associated with the quality of diabetes care?

OBJECTIVE: This study examines the association between physician gender and diabetes quality of care. RESEARCH DESIGN AND METHODS: We examined the association between the gender of primary care physicians (n = 1,686) and the quality of diabetes care they provided to their patients participating in the Translating Research Into Action for Diabetes (TRIAD) study. Main outcome measures were diabetes processes of care including receipt of dilated retinal exams, urine microalbumin/protein testing, foot exams, lipid and HbA(1c) (A1C) testing, recommendation to take aspirin, and influenza vaccination over 1 year. Intermediate outcomes included blood pressure, A1C, LDL levels, and patient satisfaction. Hierarchical regression models accounted for clustering within provider groups and health plans and adjusted for patient age, gender, race, income, education, diabetes treatment and duration, and health status, along with physician age, years of practice, and specialty. RESULTS: Compared with male physicians (n = 1,213), female physicians (n = 473) were younger, had more recently completed training, and were more often internists. Patients of female physicians (n = 4,585) were more often women and younger than patients of male physicians (n = 1,783). In adjusted analyses, patients of female physicians were slightly more likely to receive lipid measurements (predicted probability 1.09 [95% CI 1.02-1.15]) and A1C measurements (1.02 [1.00-1.05]) and were slightly more likely to have an LDL <130 mg/dl (1.05 [1.00-1.10]). CONCLUSIONS: Patients of female physicians received similar quality of care compared with patients of male physicians.     

Development and Implementation of a Model to Improve Identification of Patients Infected with HIV Using Diagnostic Rapid Testing in the Emergency Department

Objectives Infection with the human immunodeficiency virus (HIV) continues to expand in nontraditional risk groups, and the prevalence of undiagnosed infection remains relatively high in the patient populations of urban emergency departments (EDs). Unfortunately, HIV testing in this setting remains uncommon. The objectives of this study were 1) to develop a physician‐based diagnostic rapid HIV testing model, 2) to implement this model in a high‐volume urban ED, and 3) to prospectively characterize the patients who were targeted by physicians for testing and determine the proportions who completed rapid HIV counseling, testing, and referral; tested positive for HIV infection; and were successfully linked into medical and preventative care. Methods An interdisciplinary group of investigators developed a model for performing physician‐based diagnostic rapid HIV testing in the ED. This model was then evaluated using a prospective cohort study design. Emergency physicians identified patients at risk for undiagnosed HIV infection using clinical judgment and consensus guidelines. Testing was performed by the hospital's central laboratory, and clinical social workers performed pretest and posttest counseling and provided appropriate medical and preventative care referrals, as defined by the model. Results Over the 30‐month study period, 105,856 patients were evaluated in the ED. Of these, 681 (0.64%; 95% confidence interval [CI] = 0.60% to 0.69%) were identified by physicians and completed rapid HIV counseling, testing, and referral. Of the 681 patients, 15 (2.2%; 95% CI = 1.2% to 3.6%) patients tested positive for HIV infection and 12 (80%; 95% CI = 52% to 96%) were successfully linked into care. Conclusions A physician‐based diagnostic HIV testing model was developed, successfully implemented, and sustained in a high‐volume, urban ED setting. While the use of this model successfully identified patients with undiagnosed HIV infection in the ED, the overall level of testing remained low. Innovative testing programs, such as nontargeted screening, more specific targeted screening, or alternative hybrid methods, are needed to more effectively identify undiagnosed HIV infection in the ED patient population.     

CB7-01: Psychology in Primary Care: An Evaluation of Best Practices

Background/Aims Integrating psychology and mental health professionals into primary care settings has emerged as a means to improve the access to and utilization of mental health services. Three models linking psychology to primary care are: referring a patient to a psychologist located in a facility outside of the primary care physician's (PCP) office; referring a patient to a co-located psychologist who is not integrated into the PCP; integrated model where the PCP and the psychologist are co-located and communicate regarding the patient's health. The overall purpose of this project was to investigate predictors of patients' initial response patterns to their primary care physicians' referrals to psychologists across the Scott & White Healthcare system in the context of the models delineated. Methods Using clinician notes and claims data housed within the S&W electronic medical records (EMR), we identified patients with ICD-9 codes for depression (311, 300.4, 296.2, 296.3,) and anxiety disorder (308.3, 300.00) referred to mental health clinics those satisfy one of the three main psychology models mentioned above. Our main outcome variable of interest was patients' attendance at their initial appointment with psychologists (binary outcome variable yes/no). Patients' demographics (age, gender, race, ethnicity), clinics from which patients were referred, and the number of days between referral and scheduled appointment were included in the logistic regression model. Results Our preliminary results indicated that older patients were likely to attend initial appointments after being refereed by their PCP (odds ratio estimate=1.01, 95% CI: 1.006, 1.032). Patients that were seen by psychologist or mental health professional in a facility was integrated into the PCP practice were more likely (odds ratio estimate= 1.79, 95% CI: 1.12, 2.84) to attend their initial appointments compared to the other two models of care. Finally, patients with the greatest time between referral and time of scheduled appointments were less likely to attend their initial appointments. Discussion Results of this study provide useful information about how patients can receive effective mental healthcare services when the primary care physicians and psychologists work within an integrated co-located environment and communicate about the patient's health.     

Should chronic catarrh patients seen in primary care be referred for further investigations?

Background: Chronic catarrh is commonly encountered in primary care, but often presents a quandary to the clinician because the history of postnasal or pharyngeal mucus build‐up is frequently at odds with the absence of physical findings. As with certain other medically mysterious syndromes, the value of often costly investigation remains unclear in both the primary and the secondary care settings. Indeed, investigation may reassure the physician more than the patient ( 1 ) and could even prove counter‐productive through reinforcement of the patient’s belief about the presence of significant pathology ( 2 ). Aim: To establish the benefit of referral of chronic catarrh patients for specialist investigation. Design: A cross‐sectional survey. Setting: A total of 138 patients referred to secondary care with chronic catarrh, postnasal drip or throat clearing in the north of England. Methods: Subjects completed three disease‐specific symptom‐scoring questionnaires (RSI, SNOT‐20 and GETS). Investigations performed were saccharin clearance time, nasendoscopy, skinprick allergy testing and CT of sinuses. Results were compared with published values. Results: Catarrh patients scored highly on all three symptom questionnaires. Nasendoscopy was normal in 70% of patients, with the remainder demonstrating mostly simple mucus (20%), lymphoid tissue (6%) or mucopus (2%). Only 6 of the 136 patients tested had a prolonged saccharin clearance time greater than 30 min. The mean score of the 63 sinus CT scans obtained was 2.6 (normal range = 0–5). Of patients undergoing skinprick testing (n = 45), 30% reacted to one or more inhaled allergen. No rhinological investigation yielded results above that expected in the general population. Conclusion: Chronic catarrh appears to be related more to pharyngeal symptom awareness than to pathological postnasal drip or mucus over‐production. Rhinological investigations have a limited role in the management of chronic catarrh patients. The principal outcome of ENT referral is likely to be reassurance and direction towards patient self‐help information.     

Effect of patient socioeconomic status on physician profiles for prevention,disease management,and diagnostic testing costs

BACKGROUND: Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known. OBJECTIVE: To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs. RESEARCH DESIGN: Cross-sectional analysis of a managed care claims data. SUBJECTS: Five hundred sixty-eight physicians and 600,618 patients. MEASURES: Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs. RESULTS: For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES. CONCLUSIONS: Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.     

Which enrollees bypass their gatekeepers in a point-of-service plan?

BACKGROUND AND OBJECTIVES: Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN: We conducted a cross-sectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS: Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worthwhile, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS: Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.     

Structured management strategy based on the Gastro-oesophageal Reflux Disease (GERD) Questionnaire (GerdQ) vs. usual primary care for GERD: pooled analysis of five cluster-randomised European studies

Background: Response to treatment among primary care patients with gastro‐oesophageal disease (GERD) is variable. Aim: The GERD Management Project (GMP) evaluated the effectiveness of a structured management approach to GERD vs. standard treatment (usual care). Methods: Data from five cluster‐randomised clinical trials in adult primary care patients with symptoms of GERD were pooled. The structured pathway was based on the self‐administered GERD Questionnaire (GerdQ) and was compared with standard treatment. Results: 1734 patients were enrolled (structured treatment, n = 834; standard treatment, n = 900). The difference in the mean GerdQ score change from baseline favoured the structured pathway (?0.61; 95% CI: ?0.88, ?0.34; p < 0.001). The odds ratio for an indication for treatment revision at the end of follow‐up (structured vs. standard treatment) was 0.39 (95% CI: 0.29, 0.52; p = 0.001). Conclusions: Management of primary care patients with GERD can be improved by systematic stratification of patients using a patient management tool such as the GerdQ.     

Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients

BACKGROUND: Previous research shows that patient socioeconomic status (SES) affects health care, but little is known about the relative effects of patient and physician practice SES among privately insured patients. OBJECTIVE: To examine the effects of patient and physician practice SES on prevention, disease management, utilization, and cost expenditures. DESIGN: Cross-sectional analyses of claims data. SUBJECTS: Primary care physicians (568) and their adult managed care organization patients (437,743) in the Rochester, New York, area. MEASURES: Pap smears, mammograms, glycohemoglobins, and eye examinations for diabetics, physician visits, referrals, hospitalizations, costs standardized expenditures (diagnostic testing, office visits, and total), patient zip code-based SES, and physician practice SES (mean SES of patients in practice). RESULTS: After adjustment, lower SES patients had lower compliance with Pap smears, mammograms, and diabetic eye exams, and were less likely to have a referral or make any office visit, but were more likely to be hospitalized, and generated higher testing standardized expenditures. Lower physician practice SES was associated with lower adjusted Pap, mammogram, and glycohemoglobin compliance, lower office visit standardized expenditures, but higher diagnostic testing and total standardized expenditures. Patient SES effects were stronger for mammography, whereas physician practice SES effects were stronger for diagnostic testing costs. For the utilization indicators, the SES effects on utilization exhibited a linear gradient, whereas there was a threshold effect for costs. CONCLUSIONS: Patient and practice SES are independently associated with care among privately insured patients. These effects are not confined to the poorest patients but span the entire socioeconomic spectrum. Interventions to address these disparities need to be broad-based, but should also address the needs of practices with predominantly lower SES patients.     

Screening for nephropathy and antiangiotensin use among diabetic patients in an academic community medical center

The American Diabetes Association recommends routine screening for albuminuria to detect early nephropathy in all patients with diabetes mellitus. If nephropathy is identified, treatment with an antiangiotensin agent decreases progression and improves renal outcomes. Concordance with guidelines for nephropathy screening and antiangiotensin therapy among diabetic patients in a primary care setting of an academic community medical center was evaluated. Medical charts of adult patients with diabetes mellitus from February 2000 through January 2003 were retrospectively reviewed. In part 1 of the study, whether patients were screened for nephropathy at least once was recorded. In part 2 of the study, antiangiotensin prescribing was assessed in all patients and in subgroups stratified by screening. In both parts of the study, patient characteristics and comorbidities were assessed using multivariate analysis to determine their impact on the odds that a patient was screened and that antiangiotensin therapy was prescribed. Among the 329 patients included, 182 patients (55.3%) were screened for nephropathy. Patients who were screened were younger (OR=0.83 for 10-year increase, 95% CI: 0.69-0.99), less likely to have congestive heart failure (OR=0.42, 95% CI: 0.20-0.90), and more likely to be cared for by a resident physician directly supervised by an attending physician (OR=3.03; 95% CI: 1.82-5.03). A total of 215 patients (65.3%) were prescribed antiangiotensin therapy. Hypertension was a predictor of antiangiotensin therapy among all patients who were screened (OR=10.34, 95% CI: 4.45-24.01), those who were screened and negative (OR=15.46, 95% CI: 5.56-42.98), and those who were not screened (OR=10.79, 95% CI: 4.39-26.52). Among patients screened for nephropathy, coronary artery disease (OR=3.01, 95% CI: 1.05-8.63), and the presence of proteinuria (OR=4.26, 95% CI: 1.61-11.24) were predictors of antiangiotensin use. This study found that the likelihood of screening for nephropathy among diabetic patients was inversely associated with a diagnosis of congestive heart failure and increasing age. Conversely, care by a resident physician directly supervised by an attending physician increased the odds that patients would be screened. A diagnosis of hypertension and the presence of albuminuria were each associated with increased use of an antiangiotensin agent.     

Association of primary care physician sex with cervical cancer and mammography screening

Objective

To assess whether the sex of primary care physicians is associated with differing rates of cervical cancer and mammography screening in a contemporary multicultural context.

Design

Structured medical record review of a retrospectively defined cohort.

Setting

Academic urban primary care clinic in Montreal, Que.

Participants

Seven male physicians and 9 female physicians, and all female patients aged 14 to 69 years registered to one of the physicians (N = 1948).

Main outcome measures

Screening compliance rates as measured by the elapsed time between the last visit and cervical cancer screening for all women in the study. In addition, in women aged 50 to 69 years, elapsed time between the last visit and mammography screening.

Results

Crude rates of Papanicolaou tests for patients of female primary care physicians were higher than for patients of male primary care physicians in all patient age groups. The lowest rates of Pap testing were among the youngest and oldest patients. After adjustment for patient age, first language, and region of birth, as well as physician age, the odds ratio of having a Pap test was 2.24 (95% CI 1.18 to 4.28) for the patients of female physicians, relative to those of male physicians. The adjusted odds ratio for mammography screening was 1.25 (95% CI 0.97 to 1.61) for patients of female physicians.

Conclusion

Male primary care physician sex is associated with lower rates of cervical cancer screening in an urban multicultural context. The study did not detect a physician sex effect in the mammography cohort.     

Dietary guidance for older patients with diabetes mellitus and their primary caregivers using a Model Nutritional Balance Chart

Aim: Dietary control of diabetes mellitus becomes hard in care‐dependent older patients staying at home due to the difficulty of understanding nutritional balance by their primary caregivers. In the present study, an easily handled Model Nutritional Balance Chart (MNBC) for care‐dependent older patients with diabetes mellitus and their primary caregivers was investigated. Methods: Nine care‐dependent older patients with diabetes mellitus and their primary caregivers received dietary guidance using the MNBC once per month for 6 months. Nine control care‐dependent older patients with diabetes mellitus and their primary caregivers did not receive dietary guidance but cooperated in providing data once per month. The medicines for the patients were kept the same during the entire length of the study. The effectiveness of the program was judged by changes in nutritional balance and hemoglobin A1c (HbA1c) values. Results: Improvements in nutritional balance were observed in relation to fish, fruit, oil, and sugar. The HbA1c values significantly decreased after 6 months in the intervention group, while the HbA1c values in the control group did not change. Conclusion: Our guidance method seems to be useful for care‐dependent older patients with diabetes mellitus who are staying at home with their primary caregivers.     

ED Crowding Is Associated with Variable Perceptions of Care Compromise

Objectives The authors measured the association between emergency department (ED) crowding and patient and provider perceptions about whether patient care was compromised. Methods This was a cross‐sectional study of patients admitted from the ED and their providers. Surveys of patients, nurses, and resident physicians were linked. The primary outcome was agreement or strong agreement on a five‐item scale assessing whether ED crowding compromised care. Logistic regression was used to determine the association between the primary outcome and measures of ED crowding. Results Of 741 patients approached, 644 patients consented (87%); 703 resident physician surveys (95%) and 716 nursing surveys (97%) were completed. A total of 106 patients (16%), 86 residents (12%), and 173 nurses (24%) reported that care was compromised by ED crowding. In 252 cases (35%), one or more respondents reported that care was compromised. There was poor agreement over whose care was compromised. For patients, independent predictors of compromised care were waiting room time (odds ratio [OR], 1.05 for each additional 10‐minute wait [95% confidence interval {CI} = 1.02 to 1.09]) and being surveyed in a hallway bed (OR, 2.02 [95% CI = 1.12 to 3.68]). Predictors of compromised care for nurses included waiting room time (OR, 1.05 for each additional 10‐minute wait [95% CI = 1.01 to 1.08]), number of patients in the waiting room (OR, 1.05 for each additional patient waiting [95% CI = 1.02 to 1.07]), and number of admitted patients waiting for an inpatient bed (OR, 1.08 for each additional patient [95% CI = 1.03 to 1.12]). For residents, predictors of compromised care were patient/nurse ratio (OR, 1.39 for a one‐unit increase [95% CI = 1.09 to 1.20]) and number of admitted patients waiting for an inpatient bed (OR, 1.14 for each additional patient [95% CI = 1.10 to 1.75]). Conclusions ED crowding is associated with perceptions of compromised emergency care. There is considerable variability among nurses, patients, and resident physicians over which factors are associated with compromised care, whose care was compromised, and how care was compromised.     

Can ambulatory care prevent hospitalization for metabolic decompensation?

OBJECTIVE: Metabolic decompensations (MD) are hospitalizations considered preventable with appropriate ambulatory care. We tested for associations between diabetes care and MD. RESEARCH DESIGN: We retrospectively compared care between cases (MD; n = 2714) and controls (without MD; n = 10,856) using merged Veterans Health Administration and Medicare data. Logistic regression tested for associations between MD and diabetes care controlling for patient characteristics. SUBJECTS: Veterans Health Administration users with diabetes stratified into high [hemoglobin A1c (HA1c) > or =9%; n = 2532] and low (HA1c <9%; n = 6176) risk groups. MEASURES: The outcome was hospitalization for MD. Care was defined as quarterly or semiannual diabetes visits and HA1c testing during individualized 12-month baseline periods. RESULTS:: Cases averaged more diabetes visits and HA1c tests than controls (P < 0.001 for both) in the 12-month baseline period. Among the high-risk, 29.8% of cases made 4 quarterly visits compared with 29.6% of controls (P = 0.004); among the low-risk, there was no difference in semiannual visits. Among the high-risk, models showed having no visit was associated with higher odds of MD (adjusted odds ratio: 3.05; 95% confidence interval: 1.69-5.49) compared with 4 visits; individuals with 1-4 visits had similar odds of MD. More HA1c testing was weakly associated with higher odds of MD. CONCLUSIONS: MD was associated with more diabetes care, even controlling for patient characteristics. This inconsistency with the theoretical association between appropriate ambulatory care and lower MD rates indicates that MD rates may not accurately reflect diabetes care quality.     

Lipid testing among patients with diabetes who receive diabetes care from primary care physicians

OBJECTIVE: To identify factors related to lipid testing among patients with diabetes who receive diabetes care from primary care physicians. RESEARCH DESIGN AND METHODS: North Carolina Medicare claims were used to identify individuals with diabetes who received diabetes care from primary care physicians. Lipid testing was related to sociodemographic characteristics, comorbid conditions, physician specialty, and mortality. RESULTS: Based on Medicare claims from July 1997 through June 1999, 13,660 diabetic North Carolina residents with Medicare, 65-75 years of age, had received HbA(1c) testing from a single primary care physician during at least three of four consecutive 6-month time intervals. During these 2 years, 31% had no lipid profile and 24% had only one lipid profile. Caucasians were 1.6 times more likely than African Americans to receive lipid profiles. Patients not receiving state Medicare assistance were 1.4 times more likely to have a lipid profile than the presumably lower-income patients receiving assistance. Patients with stroke and heart failure were less likely to receive lipid profiles. Those with no lipid profile were almost twice as likely to die from cardiovascular disease than those with at least two lipid profiles. CONCLUSIONS: Adherence to lipid testing recommendations by primary care physicians for elderly patients with diabetes has much room for improvement. The most vulnerable patients (African Americans, the economically disadvantaged, and the medically complex) are the least likely to receive lipid testing.