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
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.
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