Gender Differences in Healthcare Utilization of Patients With Diabetes
Published Online: July 12, 2012
Heike U. Krämer, MSc; Gernot Rüter, MD; Ben Schöttker, MPH; Dietrich Rothenbacher, MD, MPH; Thomas Rosemann, MD, PhD; Joachim Szecsenyi, MD; Hermann Brenner, MD, MPH; and Elke Raum, MD, MPH
Descriptive statistics included means and proportions, respectively, on participants’ characteristics and healthcare utilization stratifi ed by gender and glycemic control. Differences between groups were tested for statistical signifi cance by 2-sided t tests and χ² tests. The Wilcoxon rank sum test was used to evaluate hospitalization and rehabilitation length of stay (2-tailed), including only patients who reported a stay. We used Poisson regression models to fit outpatient appointments (count data) or total number of prescribed medication and A1C measurements. Poisson regression returns (unadjusted and adjusted) rate ratios (RRs). Furthermore, logistic regression models were used to estimate (unadjusted and adjusted) odds ratios (ORs) for hospitalization or rehabilitation stay within the last 12 months (dichotomous) and glycemic control status (A1C level). The multivariate Poisson and logistic models were adjusted for variables selected by backward selection (P <.1) in order to identify the main independent determinants. Furthermore, effect modifi cation by glycemic status was assessed using the Breslow-Day test. For statistical testing, an alpha level of 5% was applied, and 95% confi dence intervals (CIs) calculated. SAS 9.2 (SAS Institute, Cary, North Carolina) was used throughout.
Overall, 624 men (54.5%) and 522 women (45.5%) participated in this study (Table 1). About 23% of the men and 18% of the women had PGC. Men were significantly younger than women (mean age ± standard deviation [SD]: men: 67.2 ± 10.1 years; women: 69.7 ± 10.4 years). In the PGC group, men were on average 5 years younger than women (men: 63.6 ± 11.1 years; women: 68.8 ± 10.8 years). Diabetes duration (measured in years since diabetes diagnosis) was similar for men (8.9 ± 7.2 years) and women (8.8 ± 7.2 years). Participation in a disease management program was slightly less common in men than in women (79.4% vs 81.6%).
There were statistically significant differences between men and women concerning physician-diagnosed comorbidities: men showed a higher prevalence of coronary heart disease, myocardial infarction, intermittent claudication, stroke, and nephropathy than women, whereas women more often had a diagnosed depression than men. The self-reported general health status did not differ between men and women —even if PGC status was considered. The mean BMI was almost identical between men and women. Alcohol consumption was far more common in men (77.7%) than in women (45.6%). Similarly, current smoking was more often reported by men than by women (14.8% vs 8.8%).
Overall, the vast majority of patients had completed up to 9 years of school education (72.2%). More men than women had completed 13 years or more of education. More men than women were still married (81.9% vs 59.7%). About 9% of all men but 18% of all women reported living alone. The majority of the patients were already retired (63%). Employment was more common in men, especially in the group with PGC (40.7% vs 16.7%).
The mean total number (± standard deviation) of GP appointments during the last 3 months was 2.5 ± 2.4 for men and 2.6 ± 2.5 for women, respectively (Table 2). Among patients with PGC, men had on average signifi cantly fewer appointments with their GPs or medical specialists than women (GP appointments: men: 2.4 ± 2.9, women: 3.3 ± 3.0; medical specialist appointments: men: 0.8 ± 1.3, women: 1.2 ± 1.5) (GP: P = .03; medical specialist: P = .05). The mean total number of prescribed medications was 5.7 ± 2.6 in men and 6.1 ± 2.5 in women, respectively. A statistically signifi cant gender difference in prescribed medication was evident in the group of patients with PGC: women received more medication than men (men: 5.8 ± 2.6, women: 6.8 ± 2.3, P = .0002).
About 17% of the participants reported a hospitalization during the last 12 months. There were small, non-signifi cant gender differences in regard to hospitalization in the respective PGC groups: more women (24.7%) than men with PGC (16.7%) were hospitalized, but men with PGC stayed on average about 1 day longer in the hospital than women with PGC. In the group of patients with an A1C <7.5%, hospitalized women stayed on average 3 days longer in the hospital than men.
Overall, about 8% of the men and 9% of the women reported a rehabilitation stay during the last 12 months. In the group of patients with PGC, women stayed on average 11 days longer than men, and in the group with an A1C <7.5%, women who had a rehabilitation stayed on average 6 days longer than men (P = .01).
Table 3 shows the results of the Poisson regression analyses of the outpatient care setting: overall, GP appointments of men and women seemed to be very similar. However, after stratification for glycemic status and full adjustment for the aforementioned covariates, men had signifi cantly fewer GP appointments than women (fully adjusted RR = 0.70, 95% CI: 0.53-0.91) in the PGC group but not in the non-PGC group.
Men, in general, had fewer specialist appointments than women (fully adjusted RR = 0.83; 95% CI: 0.69-1.00). This trend was similar for both glycemic control groups: for patients with an A1C <7.5% (fully adjusted RR = 0.84, 95% CI: 0.69-1.02) and for patients with PGC (fully adjusted RR = 0.85, 95% CI: 0.54-1.35).
We found a lower medication rate in men than women. This difference persisted after control for covariates including comorbidities in the fully adjusted model (fully adjusted RR = 0.94; 95% CI: 0.89-0.99). Also, among patients with PGC, we observed a statistically signifi cant gender difference (fully adjusted RR = 0.89; 95% CI: 0.80-0.99).
Table 4 shows the results of logistic regression analyses for the inpatient care setting. No significant variation by gender was found, neither for hospitalization nor for rehabilitation (hospitalization: fully adjusted OR for men compared with women = 0.92; 95% CI: 0.65-1.29; rehabilitation: fully adjusted OR = 0.84; 95% CI: 0.54-1.32). Also, no significant association was found after stratification for glycemic status.
There was no effect modification by glycemic status for outpatient or inpatient healthcare utilization (Breslow-Day test or Cochran-Mantel-Haenszel statistics: P >.05).
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