Failure to Utilize Diabetes Health Services Following a Referral

Summary

Principal Investigator: Andrew John Karter
Abstract: DESCRIPTION (provided by investigator): This application addresses broad Challenge Area (01) Behavior, Behavioral Change, and Prevention and specific Challenge Topic, 01-DK-103 Improved understanding of behavioral and social factors related to non- Adherence in people with diabetes. We propose to study patterns and predictors of diabetes patients'failure to utilize referred health services (e.g., standard lab tests, specialty visits, health education). These preventive health services are particularly important in the care of diabetes given the disease complexity, need for continual monitoring, and frequent intensification. This project will inform policy in two areas of importance to the NIH: (1) how to address poor adherence among patients with diabetes and (2) how to reduce health disparities. Findings will help us better understand the potentially high-cost patients who do not adhere to their diabetes treatment plan despite full access to integrated, pre-paid health care and allow identification of barriers to care. The project uses data from an NIH funded study, The Diabetes Study of Northern California (DISTANCE) plus new data captured from the Kaiser Permanente electronic health record (EHR). The study has immediate and longer-term public health implications, given that repeated non-utilization ("persistent non-utilization") may adversely affect continuity of care, and increase the risk for serious and costly events. This study is feasible within the two-year time frame of the challenge grant award. The investigator team has demonstrated productivity, combines expertise in adherence and diabetes health services research, and is highly experienced in acquiring and analyzing the data involved. ABSTRACT Poor adherence to a medical treatment plan is a serious public health problem in diabetes. While some aspects of adherence, particularly adherence to medications, have been studied extensively, much less is known about adherence to (utilization of) referrals for health services (e.g., standard lab tests, specialty visits, health education). These health services are vital in the care of diabetes given the disease complexity, need for continual monitoring, and frequent intensification. Up until now, quality of and access to care have been traditionally assessed from utilization records. An important limitation of such data is that it cannot differentiate between two causes of non-utilization: 1) the healthcare provider did not offer the care (by prescription or referral) versus 2) non-utilization of offered care. While healthcare providers may assume that their patients will use a health service following a referral, it is virtually unknown to what extent patients fail to do so. Under- utilization in certain subgroups, particularly among minority and socioeconomically disadvantaged patients, has been largely attributed to social disparities in access rather than under-utilization of offered care (i.e., inadequate adherence). While resources are needed to increase access for vulnerable populations, we must consider that there is also sub-optimal uptake of offered services even where access is not at issue. In this study, we take advantage of the electronic health record (EHR) system which captures electronic referral and prescribing within a large, integrated health care delivery system (Kaiser Permanente). The EHR enables us to investigate non-utilization of referred health services. This potentially has great public health importance given that repeated non-utilization ("persistent non-utilization") may adversely affect continuity of care, and increase the risk for serious and costly events. Understanding the prevalence, social patterns, patient-, provider- and system-level predictors of non-utilization and persistent non-utilization will allow the design of interventions aimed at reducing this form of non-adherence. Findings will also inform a more accurate and valid definition of quality of care and access, and have important applications for our understanding of social disparities in the quality of care. Study subjects will include members of the Kaiser Permanente Northern California Diabetes Registry, a large, well-characterized, ethnically diverse, insured population of managed care patients with diabetes mellitus. Socially disadvantaged patients are well represented in this study population, which has relatively uniform access to and quality of care, unlike most population-based samples. Given that 92 per cent of Americans with diabetes have health insurance, findings from this insured population should have broad public health relevance. Moreover, we will benefit from the rich patient-level data provided by the 20,188 diabetic patients in the DISTANCE cohort. Given this will be the first, large epidemiological study to assess non- utilization of referred care, it will provide a more comprehensive understanding of how nonadherence impacts health and may inform the design of future interventions aimed at reducing health disparities. We have evidence that a small proportion of patients with diabetes within an integrated health plan fail to utilize care following a referral for covered health services (e.g., standard lab tests, specialty visits, health education). These non-utilizing patients lack continuity of care, are at high risk of adverse events, and may end up costing the healthcare systems much more than patients who utilize offered care. PUBLIC HEALTH RELEVANCE: In this study, we will evaluate the prevalence of non-utilization and persistent (repeated) non-utilization for referred health services for diabetes. We will then evaluate social disparities and other patient-, provider- and system-level predictors of non-utilization. Understanding non-utilization will facilitate the design interventions aimed at reducing this form of non-adherence. Findings will also inform a more accurate and valid definition of quality of care and access, and have important application for our understanding of social disparities in the quality of care. This project will help us better understand patients who are "falling through the cracks" despite full access to integrated health care, and allow healthcare delivery systems to modify their programs to better serve their membership.
Funding Period: ----------------2009 - ---------------2011-
more information: NIH RePORT

Top Publications

  1. pmc Differences in the clinical recognition of depression in diabetes patients: the Diabetes Study of Northern California (DISTANCE)
    Darrell L Hudson
    Center for Diabetes Translational Research, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA
    Am J Manag Care 19:344-52. 2013
  2. pmc Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE)
    Amy M Bauer
    Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195 6560, USA
    J Gen Intern Med 28:1181-7. 2013
  3. pmc Neighborhood deprivation and change in BMI among adults with type 2 diabetes: the Diabetes Study of Northern California (DISTANCE)
    Pamela J Stoddard
    University of California, San Francisco, CA, USA
    Diabetes Care 36:1200-8. 2013
  4. pmc Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study
    Wayne Katon
    Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, 98195, USA
    Arch Gen Psychiatry 69:410-7. 2012
  5. pmc Ethnic differences in appointment-keeping and implications for the patient-centered medical home--findings from the Diabetes Study of Northern California (DISTANCE)
    Melissa M Parker
    Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612, USA
    Health Serv Res 47:572-93. 2012
  6. pmc Ethnic differences in the development of albuminuria: the DISTANCE study
    Andy I Choi
    Kaiser Permanente, Division of Research, Oakland, CA 94612, USA
    Am J Manag Care 17:737-45. 2011
  7. pmc Adherence to laboratory test requests by patients with diabetes: the Diabetes Study of Northern California (DISTANCE)
    Howard H Moffet
    Kaiser Permanente Division of Research, Oakland, CA 94612, USA
    Am J Manag Care 17:339-44. 2011
  8. pmc Correlates of quality of life in older adults with diabetes: the diabetes & aging study
    Neda Laiteerapong
    Department of Medicine, University of Chicago, Chicago, IL, USA
    Diabetes Care 34:1749-53. 2011
  9. pmc Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE)
    Courtney R Lyles
    University of Washington, Department of Health Services, School of Public Health, Seattle, WA 98195, USA
    J Health Care Poor Underserved 22:211-25. 2011
  10. pmc The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system-results from the diabetes study of northern California (DISTANCE)
    Urmimala Sarkar
    UCSF Center for Vulnerable Populations, Department of Medicine, UCSF Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California 94143 1364, USA
    J Health Commun 15:183-96. 2010

Scientific Experts

Detail Information

Publications12

  1. pmc Differences in the clinical recognition of depression in diabetes patients: the Diabetes Study of Northern California (DISTANCE)
    Darrell L Hudson
    Center for Diabetes Translational Research, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA
    Am J Manag Care 19:344-52. 2013
    ..We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes...
  2. pmc Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE)
    Amy M Bauer
    Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195 6560, USA
    J Gen Intern Med 28:1181-7. 2013
    ..Previous studies have reported that health literacy limitations are associated with poorer disease control for chronic conditions, but have not evaluated potential associations with medication adherence...
  3. pmc Neighborhood deprivation and change in BMI among adults with type 2 diabetes: the Diabetes Study of Northern California (DISTANCE)
    Pamela J Stoddard
    University of California, San Francisco, CA, USA
    Diabetes Care 36:1200-8. 2013
    ..To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes...
  4. pmc Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study
    Wayne Katon
    Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, 98195, USA
    Arch Gen Psychiatry 69:410-7. 2012
    ..Although depression is a risk factor for dementia in the general population, its association with dementia among patients with diabetes mellitus has not been well studied...
  5. pmc Ethnic differences in appointment-keeping and implications for the patient-centered medical home--findings from the Diabetes Study of Northern California (DISTANCE)
    Melissa M Parker
    Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612, USA
    Health Serv Res 47:572-93. 2012
    ..To examine ethnic differences in appointment-keeping in a managed care setting...
  6. pmc Ethnic differences in the development of albuminuria: the DISTANCE study
    Andy I Choi
    Kaiser Permanente, Division of Research, Oakland, CA 94612, USA
    Am J Manag Care 17:737-45. 2011
    ..To determine whether ethnic differences in the incidence of albuminuria are present in patients with diabetes, and to identify social, behavioral, and provider factors that explain ethnic differences...
  7. pmc Adherence to laboratory test requests by patients with diabetes: the Diabetes Study of Northern California (DISTANCE)
    Howard H Moffet
    Kaiser Permanente Division of Research, Oakland, CA 94612, USA
    Am J Manag Care 17:339-44. 2011
    ..To estimate rates and predictors of clinical laboratory test completion by patients with diabetes after provider referral...
  8. pmc Correlates of quality of life in older adults with diabetes: the diabetes & aging study
    Neda Laiteerapong
    Department of Medicine, University of Chicago, Chicago, IL, USA
    Diabetes Care 34:1749-53. 2011
    ..To evaluate associations between health-related quality of life (HRQL) and geriatric syndromes, diabetes complications, and hypoglycemia in older adults with diabetes...
  9. pmc Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE)
    Courtney R Lyles
    University of Washington, Department of Health Services, School of Public Health, Seattle, WA 98195, USA
    J Health Care Poor Underserved 22:211-25. 2011
    ..We examined possible determinants of self-reported health care discrimination...
  10. pmc The literacy divide: health literacy and the use of an internet-based patient portal in an integrated health system-results from the diabetes study of northern California (DISTANCE)
    Urmimala Sarkar
    UCSF Center for Vulnerable Populations, Department of Medicine, UCSF Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California 94143 1364, USA
    J Health Commun 15:183-96. 2010
    ....
  11. pmc Social disparities in dental insurance and annual dental visits among medically insured patients with diabetes: the Diabetes Study of Northern California (DISTANCE) Survey
    Howard H Moffet
    Kaiser Permanente, Division of Research, 2000 Broadway, Oakland, CA 94612, USA
    Prev Chronic Dis 7:A57. 2010
    ..People with diabetes are at increased risk of periodontal disease and tooth loss. Healthy People 2010 set a goal that 71% or more of people with diabetes should have an annual dental exam...
  12. pmc Barriers to insulin initiation: the translating research into action for diabetes insulin starts project
    Andrew J Karter
    Division of Research, Kaiser Permanente, Oakland, California, USA
    Diabetes Care 33:733-5. 2010
    ..Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription...