Elsevier

Preventive Medicine

Volume 105, December 2017, Pages 257-264
Preventive Medicine

Frequency and predictors of missed visits to primary care and eye care providers for annually recommended diabetes preventive care services over a two-year period among U.S. adults with diabetes

https://doi.org/10.1016/j.ypmed.2017.09.019Get rights and content

Highlights

  • 51.9% of the sample missed an annual visit to a primary care or eye care provider over a 2-year period

  • Primary care-based screening for retinopathy could reach most individuals with diabetes

  • Missing visits was more likely for those without health insurance or a usual source of healthcare

  • Missing visits was more likely for those with no diabetes-related complications or comorbidities

Abstract

This paper examines the patterns of visits to primary care and eye care providers for annually recommended diabetes preventive care services over a two-year period in a sample of U.S. adults aged 18 years and older with diabetes drawn from the 2008–2013 Medical Expenditure Panel Survey-Household Component (n = 3982). The four-category outcome variable was defined based on the four possible combinations of whether an individual missed an annual visit to a primary care provider for preventive care services in at least one year over the two-year period and whether the individual missed an annual visit to an eye care provider in at least one year over this period. Descriptive statistics and a multinomial logistic regression model were estimated. 51.9% of the sample missed an annual visit to a primary care or eye care provider for preventive care services over a two-year period. Although 48.8% of the sample missed at least one annual visit to an eye care provider, 85.6% of these individuals did visit a primary care provider for preventive care services during the year they did not visit an eye care provider. This suggests that primary care-based screening for diabetic retinopathy could reach most individuals who do not receive regular eye care. Regression results particularly relevant for potential interventions were that missing annual visits was significantly more likely for individuals without health insurance or a usual source of healthcare and for those who were not receiving diabetes treatments and did not have or were not aware of having diabetes-related complications.

Introduction

Approximately 12.3% of the U.S. population aged 20 and older has diabetes (Menke et al., 2015). Complications of diabetes are extensive and include cardiovascular disease, diabetic retinopathy, glaucoma, cataracts, diabetic kidney disease, neuropathy, and increased severity of periodontal disease and influenza (American Diabetes Association (ADA), 2015).1 Diabetes is the 7th leading cause of death in the U.S. and it is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness in the U.S. (ADA, 2015). Many diabetes complications can be prevented or postponed through lifestyle modifications and medical interventions and the severity of many complications can be reduced through early detection and timely treatment (ADA, 2015). As a result, the ADA recommends that all individuals with diabetes annually receive a comprehensive foot examination, lipid measurement, dilated eye examination, urinary albumin screening, flu vaccination, and dental exam, and at least two hemoglobin A1c (HbA1c) tests (ADA, 2015). The ADA also recommends blood pressure measurement at every routine visit (ADA, 2015). Recent estimates find that adherence to these preventive care service recommendations is suboptimal; the percentage of U.S. adults with diabetes who received these services over the course of a year ranged from 60% for flu vaccinations to 88.2% for lipid measurement (Ali et al., 2013).

Adherence over time to annual diabetes preventive care service recommendations by an individual with diabetes has implications for the individual's health and longitudinal adherence patterns among the group of individuals with diabetes have implications for the need for and targeting of interventions to increase recommendation adherence (ADA, 2015). Four prior studies have looked at longitudinal adherence patterns among U.S. adults with diabetes; three of these studies focused exclusively on the receipt of eye examinations (Fitch et al., 2015, Gregg et al., 2010, Lee et al., 2003, Sloan et al., 2014). These studies all found that a substantially higher percentage of adults with diabetes missed an annually recommended service during at least one year over a period of years than missed the service during a single year.

In order to adhere to diabetes preventive care service recommendations, individuals with diabetes must seek care from a variety of different types of health care providers. Dilated eye examinations may only be performed by ophthalmologists or optometrists and dental exams may only be performed by dentists or dental hygienists (Lubell, 2014, Buchmueller et al., 2016). The other recommended diabetes preventive care services are typically provided by primary care physicians, endocrinologists, or diabetologists (these types of providers are hereafter referred to as “diabetes primary care providers” for ease of explanation) (Nathan, 2015). This paper builds on the previous research by examining the combination of types of health care providers an individual visited for annually recommended diabetes preventive care services over a 2-year period. This paper also adds to the prior research by using a sample that included individuals with and without health insurance. Descriptive statistics are used to determine how variables related to the benefits and costs of visiting diabetes preventive care service providers differed across individuals who received services from different combinations of types of providers and a multinomial logistic regression model is used to explore which of these variables are significant predictors of visit patterns. It is hypothesized that factors related to lower benefits or higher costs of visiting diabetes preventive care service providers will be associated with a greater likelihood of missing more types of provider visits. Factors associated with provider-type visit decisions are potential targets for interventions that aim to influence the preventive care choices of individuals with diabetes.

Section snippets

Sample

This paper used publicly-available data on adults aged 18 years and older with diabetes drawn from the 2008–2013 Medical Expenditure Panel Survey-Household Component (MEPS-HC) (Agency for Healthcare Research and Quality, 2017). The MEPS-HC is a nationally representative sample of the U.S. civilian noninstitutionalized population. The MEPS-HC collects data from a sample of households through an overlapping panel design. Interviews covering two full calendar years are conducted for each panel.

Descriptive statistics

14.2% of the sample was in the MISSED_BOTH category; 34.6% of the sample was in the MISSED_EYE category; 3.1% of the sample was in the MISSED_DPC; and 48.1% of the sample was in the MISSED_NEITHER category. 3% of the sample missed an annual visit to a diabetes primary care provider in both years of MEPS participation; 20% of the sample missed an annual visit to an eye care provider in both years; and 2.3% of the sample missed annual visits to both diabetes primary care and eye care providers in

Discussion

The descriptive results revealed that a substantially higher percentage of individuals with diabetes missed an annual visit to a diabetes primary care or eye care provider for preventive care services over a two-year period than missed a visit in a single year. These findings suggest that longitudinal data is needed to understand the adherence profiles of individuals and to determine the portion of individuals with diabetes who should be considered as potential targets for interventions to

Conclusions

Even over a short two-year period more than half of the sample of adults with diabetes missed at least one annual visit to a diabetes primary care or eye care provider for preventive care services. However, given that few individuals missed all visits for recommended preventive care services over this period, strategies to increase the receipt of recommended services that are based in the practices of diabetes preventive care service providers would be expected to eventually reach almost all

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Acknowledgments

Christopher Sanchez provided excellent research assistance in the collection of background material and previous research relevant for this paper.

Conflict of interest statement

The author declares that there are no conflicts of interest.

References (21)

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    Numerous studies have examined the relationships between several demographic and economic factors and the receipt of some preventive care practices among adults with diabetes in the US. These studies found that factors including race, socioeconomic status, and health insurance are associated with receiving that care (Pu and Chewning, 2013; Tran et al., 2017; Gibson, 2017; Centers for Disease Control and Prevention, 2005; Hu et al., 2014; Li et al., 2010; Luo et al., 2018). Nevertheless, previous studies focused on receiving some of the preventive care measures at a time and did not include other factors that may affect receiving that care, such as other chronic physical and mental diseases.

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