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The American Journal of Managed Care October 2014
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Increasing Preventive Health Services via Tailored Health Communications
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The Duration of Office Visits in the United States, 1993 to 2010
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Gary Epstein-Lubow, MD; Rosa R. Baier, MPH; Kristen Butterfield, MPH; Rebekah Gardner, MD; Elizabeth Babalola, BA; Eric A. Coleman, MD, MPH; and Stefan Gravenstein, MD, MPH
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Eleftherios S. Xenos, MD, PhD; Jessica A. Lyden, BSc; Ryan L. Korosec, MBA, CPA; and Daniel L. Davenport, PhD
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Healthcare Utilization and Diabetes Management Programs: Indiana 2006-2010
Tilicia L. Mayo-Gamble, MA, MPH; and Hsien-Chang Lin, PhD

Healthcare Utilization and Diabetes Management Programs: Indiana 2006-2010

Tilicia L. Mayo-Gamble, MA, MPH; and Hsien-Chang Lin, PhD
This study identifies factors associated with seeking physician assistance and participating in a diabetes self-management class in patients with type 2 diabetes mellitus.
ABSTRACT
Objectives
Healthcare utilization and participation in diabetes management programs have shown to be beneficial to overall health in patients with type 2 diabetes mellitus (T2DM). To improve the effectiveness of healthcare activities on diabetes health outcomes, factors associated with healthcare activities such as physician seeking and participating in a diabetes management class need to be identified.

Design and Methods
A retrospective multi-year cross-sectional analysis was conducted. Data were collected using data sets from the 2006 to 2010 Behavioral Risk Factor Surveillance System Survey. A Poisson regression was conducted to capture the influence of predisposing, enabling, and need factors on the number of physician visits for diabetes. A logistic regression was conducted to capture the influence of the aforementioned factors on participation in a diabetes management class.

Results
Results of the Poisson regression indicate patients who were taking insulin, more frequently check for sores, or have hemoglobin exams, had made more physician visits (incident rate ratios = 1.34, 1.04, and 1.05, respectively; all P <.01). Results of the logistic regression indicate patients who were taking insulin or more frequently check for sores (odds ratio [OR] = 1.48, 1.37, 1.43, 0.74, 1.30, 1.07, and 1.06, respectively; all P <.01), were more likely to participate in a diabetes management class. Results also indicated patients who were male or married were less likely to participate in a diabetes management class (OR = 0.69, P <.05; OR = 0.81, P <.01 respectively).

Conclusions
Evidence supports sociological factors as important facilitators promoting healthcare utilization in patients with increased T2DM severity levels. Interventions to improve healthcare utilization should acknowledge sociological factors, particularly self-care factors.

Am J Manag Care. 2014;20(10):e461-e468
  • Based on the findings of this study, sociological factors are important facilitators in promoting healthcare utilization, particularly in patients with increased severity levels of type 2 diabetes mellitus.
  • The findings from this study show particularly strong associations between self-care factors and diabetes healthcare utilization, such as seeking guidance from a physician and participating in a diabetes self-management class.
  • Self-care activities should be encouraged by healthcare professionals, as they are strong indicators for participation in diabetes education and self-management programs.
Diabetes affects more than 25 million Americans.1,2 This disease continues to be a growing public health concern in the United States, including Indiana. The prevalence of diabetes has reached epidemic levelsincreaseing by almost 5% each year since 2000 and by over 50% from 2000 to 2009.1-4 Type 2 diabetes mellitus (T2DM) accounts for more than 90% of individuals diagnosed with diabetes.3,4 In 2010, an estimated 9.3% of adults in Indiana reported that they had been diagnosed with diabetes, exceeding the US diabetes prevalence of 8.3%.1,2,4,5

Self-care is an important element of any diabetes treatment plan. Studies have addressed the importance of diabetes self-care activities6; however, limited research exists on the impact of self-care activities on utilizing such beneficial healthcare services as diabetes management programs. To improve the effectiveness of healthcare utilization in T2DM patients in Indiana, and to gain knowledge about why such patients may choose it, it would be valuable to identify factors associated with healthcare utilization activities. This study identifies factors associated with patients with T2DM choosing to 1) seek physician assistance, and/ or 2) participate in a diabetes self-management class.

METHODS

We implemented a retrospective multiyear cross-sectional study to identify factors associated with 2 forms of healthcare utilization in patients with T2DM. This study tests 2 hypotheses: 1) the number of times a patient with diabetes seeks physician assistance is determined by need, enabling, and predisposing (including behavioral) factors; and 2) patients who participate in self-care activities are more likely to participate in a diabetes management class.

Conceptual Framework

The Andersen model of healthcare utilization, widely used for characterizing factors that lead to healthcare utilization provided the conceptual foundation for the hypotheses. It measures the impact of sociological determinants of healthcare utilization rates and consumption of medical resources in addition to genetic and need factors.7 In this model, healthcare utilization is influenced by factors in 3 categories: predisposing characteristics (age, sex, race), enabling/inhibiting factors (employment status, health insurance status, income level, education level, marital status), and need for care (insulin dependence, eye status, perceived overall health status, stroke).8,9 The Figure shows predisposing characteristics, enabling factors, need, and the introduction of a fourth category entitled self-care factors. Self-care includes a range of activities such as self-monitoring of blood glucose and going to the doctor to have one's feet checked.8 Literature suggests self-care as key to overall diabetes management.10

Numerous studies have discussed the factors that are barriers and catalysts for self-management and self-care. 6,10-13 However, there is little research on the role of self-care factors in choices made about healthcare utilization, such as seeing a physician and participating in a self-management class. Therefore, this study has included, as a factor, the category of self-care practices in which diabetes patients currently participate, including glycemic control, glucose self-monitoring, checking glycated hemoglobin (A1C), and monitoring for physical changes (sores) that can indicate diabetes complications. Covariates were selected based on relevance to categories defined by Andersen’s model and literature on T2DM.

Study Sample

This study used the Behavioral Risk Factor Surveillance System (BRFSS) to analyze healthcare utilization among Indiana residents with T2DM. A collaborative project of the CDC and the 50 US states, the BRFSS is an ongoing data collection program designed to examine behavioral risk factors among adult populations. 14,15 Since interviewing each person is not feasible, a random sample is drawn in which all persons have a known chance of selection.14 To adjust for differences in probability of selection and nonresponse, and to obtain representative state population-based estimates, post stratification sampling weights in BRFSS were used in all statistical analyses in this study.15 The present study used data from 2006 to 2010 and included only Indiana residents (N = 3459, weighted N = 332,544). Study inclusion consisted of patients who responded “yes” to the BRFSS question, “Have you ever been told by a health professional that you have diabetes?” This study obtained exemption for data access to the publicly available BRFSS data sets from the Institutional Review Board of the authors’ institution.

Measurements

The dependent variables, recoded directly from the BRFSS data set, were 1) number of times a physician was seen for diabetes and 2) participation in a diabetes management program. These variables were responses to the BRFSS questions, “About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?” and “Have you ever taken a course or class in how to manage your diabetes yourself?” Covariates were categorized based on the conceptual framework. The first category, predisposing factors, included age, race, and sex. Patients’ races were categorized as non-Hispanic white, non-Hispanic black, and other. Age was recoded into 5 categories (aged, in years, 19-30, 31-40, 41-50, 51-65, and >65); this categorization controls for the impact of T2DM every 10 years, with the exception being the group aged 51-65 years, which was categorized as 15 years due to the final cetegory, >65 years, being the age most affected by T2DM. Sex was included as a binary variable.

The second category, enabling factors, included education level, income level, employment status, marital status, and health insurance status. Education level was recoded from the BRFSS data set as no schooling, ≤high school diploma, or some college/college graduate. Employment status was recoded from the data set as do not work, employed for wages, or retired. Annual income level was recoded as <$25,000, $25,000-$50,000, or >$50,000. Marital status and health insurance status were included as binary variables.

The third category, need factors, included general health status, insulin dependence, stroke, and whether diabetes has affected the eyes. General health status was recoded as excellent, very good/good, or fair/poor. Stroke, insulin dependence, and diabetes’ effect on eyes were all included as binary variables.

The final category, self-care factors, included the number of times in the past 12 months A1C was checked, the number of times in the past 30 days glucose were checked, and the number of times in the past 12 months that a physician checked for sores. All self-care variables were included as continuous variables.

Statistical Analysis

Descriptive statistics on all outcome variables and covariates were obtained. A Poisson regression was used to capture the number of times a physician was seen for diabetes, while controlling for the aforementioned covariates.

The second step of the analysis used logistic regression to examine factors that influenced participation in a diabetes management class, while controlling for predisposing characteristics, enabling factors, need factors, and self-care factors. Stata version 13 was used to conduct all statistical analyses.16 Statistical tests were conducted using a .05 alpha level and a 95% confidence interval.

RESULTS

A total weighted number of 3604 patients with diabetes, representative of 332,554 patients with diabetes in Indiana, were studied. Table 1 outlines the descriptive statistics of the study population. A majority of the study population was male (52.97%), non-Hispanic white (85.74%), and aged between 31 and 40 years (40.13%). The mean number of times a doctor was seen for diabetes within the previous 12 months was 3.28 (SD = 0.10). Participants who had taken a diabetes management class within the past 12 months represented 61.32% of the study population.

The first regression analysis was the Poisson regression conducted using the outcome variable, “Number of times a physician was seen for diabetes in the past 12 months.” These results, including the incident rate ratios (IRRs) and the 95% CIs of covariates, are shown in Table 2. The IRR for participants aged 51 to 65 years is 1.64 times higher than that for diabetics aged >65 years. Insulin dependence indicated an IRR 1.34 times higher than that for the non–insulin dependent. Likewise, the IRR for participants who self-reported race as non-Hispanic white is 0.22 times lower than that for non-Hispanic black, holding the other variables at constant. With each additional time a patient had his A1C checked or was checked for sores, there was an increased IRR in the number of times a physician was seen for diabetes (IRR = 1.05 and IRR = 1.04, respectively), holding the other variables at constant.

The second regression analysis, logistic regression, was conducted using the outcome variable, “Participation in a diabetes management class,” in the last 12 months. These results, including the odds ratios (ORs) and the 95% CIs of covariates, are shown in Table 3. Results indicated that patients in the groups of individuals aged 19 to 30 years, 31 to 40 years, 41 to 50 years, and 51 to 65 years were more likely to participate in a diabetes management class compared with participants aged more than 65 years (ORs = 3.69, 5.27, 5.16, and 4.48, respectively; 95% CIs, 1.68-8.11, 2.44-11.40, 2.28-11.68, and 1.72-11.67, respectively). Participants who were insulin-dependent were more likely to participate in a diabetes management class compared with participants who were not insulin-dependent (OR = 1.82; 95% CI, 1.43-2.31). For each increase in the number of times a physician checked a participant for sores, they were more likely to participate in a diabetes management class (OR = 1.09; 95% CI, 1.04-1.14).

DISCUSSION

While previous studies indicate increased use of healthcare services after diagnosis of T2DM, this study provides evidence that sociological factors influence variation in healthcare utilization. Sociological factors were significantly associated with the number of times a physician was seen for diabetes and with participation in a diabetes management class.

 
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