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Perceived access problems among patients with diabetes in two public systems of care

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Abstract

OBJECTIVE: We examined the prevalence of access problems among public clinic patients after participating in trials of automated telephone disease management with nurse follow-up.

DESIGN: Randomized trial.

SETTING: General medicine clinics of a county health care system and a Veterans Affairs (VA) health care system.

PARTICIPANTS: Five hundred seventy adults with diabetes using hypoglycemic medication were enrolled and randomized; 520 (91%) provided outcome data at 12 months.

INTERVENTION: Biweekly automated telephone assessments with telephone follow-up by diabetes nurse educators.

MEASUREMENTS AND MAIN RESULTS: At follow-up, patients reported whether in the prior 6 months they had failed to obtain each of six types of health services because of a financial or nonfinancial access problem. Patients receiving the intervention were significantly less likely than patients receiving usual care to report access problems (adjusted odds ratio [AOR], 0.61; 95% confidence interval [CI], 0.43 to 0.97). The risk of reporting access problems was greater among county clinic patients than VA patients even when adjusting for their experimental condition, and socioeconomic and clinical risk factors (AOR, 1.61; 95% CI, 1.02 to 2.53). County patients were especially more likely to avoid seeking care because of a worry about the cost (AOR, 2.82; 95% CI, 1.48 to 5.37).

CONCLUSIONS: Many of these public sector patients with diabetes reported that they failed to obtain health services because they perceived financial and nonfinancial access problems. Automated telephone disease management calls with telephone nurse follow-up improved patients’ access to care. Despite the impact of the intervention, county clinic patients were more likely than VA patients to report access problems in several areas.

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References

  1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–86.

    Article  Google Scholar 

  2. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.

    Article  Google Scholar 

  3. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet. 1998;352:854–65.

    Article  Google Scholar 

  4. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703–13.

    Google Scholar 

  5. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 1999;22:S32-S41.

    Google Scholar 

  6. Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Intern Med. 1995;10:59–66.

    Article  PubMed  CAS  Google Scholar 

  7. Aubert RE, Herman WH, Waters J, et al. Nurse care management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med. 1998;129:605–12.

    PubMed  CAS  Google Scholar 

  8. Weinberger M, Tierney WM, Booher P, Katz BP. Can the provision of information to patients with osteoarthritis improve functional status? A randomized, controlled trial. Arthritis Rheum. 1989;32:1577–83.

    Article  PubMed  CAS  Google Scholar 

  9. Debusk RF, Houston Miller N, Superko HR, et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721–9.

    PubMed  CAS  Google Scholar 

  10. Wasson J, Gaudette C, Whaley F, et al. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788–93.

    Article  PubMed  CAS  Google Scholar 

  11. Kobak KA, Taylor LV, Dottle SL, et al. A computer-administered telephone interview to identify mental disorders. JAMA. 1997;278:905–10.

    Article  PubMed  CAS  Google Scholar 

  12. Kobak KA, Taylor LV, Dottle SL, et al. Computerized screening for psychiatric disorders in an outpatient community mental health clinic. Psychiatr Serv. 1997;48:1048–57.

    PubMed  CAS  Google Scholar 

  13. Leirer VO, Morrow DG, Pariante G, et al. Increasing influenza vaccination adherence through voice mail. J Am Geriatr Soc. 1989;37:1147–50.

    PubMed  CAS  Google Scholar 

  14. Linkens RW, Dini EF, Watson G, et al. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Arch Pediatr Adolesc Med. 1994;148:908–14.

    Google Scholar 

  15. Stehr-Green PA, Dini EF, Lindegren ML, Patriarca PA. Evaluation of telephone computer-generated reminders to improve immunization coverage at inner-city clinics. Public Health Rep. 1993;108:426–30.

    PubMed  CAS  Google Scholar 

  16. Lieu TA, Capra AM, Makol J, Black SB, Shinefield HR. Effectiveness and cost-effectiveness of letters, automated telephone mesages, or both for underimmunized children in a health maintenance organization. Pediatrics. 1998;101:E3.

    Google Scholar 

  17. Friedman RH, Kazis LE, Jette A, et al. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens. 1996;9(4 Pt 1):285–92.

    Article  PubMed  CAS  Google Scholar 

  18. Tanke ED, Leirer VO. Automated telephone reminders in tuberculosis care. Med Care. 1994;32:380–9.

    Article  PubMed  CAS  Google Scholar 

  19. Gaskin DJ, Hadley J. Identify urban safety net hospitals and the populations they serve. Abstract Book of the Association for Health Services Research. 1997;14:62–3. Abstract.

    Google Scholar 

  20. Piette JD, Weinberger M, McPhee SJ, Mah CA, Kraemer FB, Crapo LM. Can automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? A randomized controlled trial. Am J Med. 2000;108:20–7.

    Article  PubMed  CAS  Google Scholar 

  21. Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized controlled trial. Med Care. 2000;38:218–30.

    Article  PubMed  CAS  Google Scholar 

  22. Hafner-Eaton C. Physician utilization disparities between the uninsured and insured: comparisons of the chronically ill, acutely ill, and well nonelderly populations. JAMA. 1993;269:787–92.

    Article  PubMed  CAS  Google Scholar 

  23. Newacheck PW. Access to ambulatory care for poor persons. Health Serv Res. 1988;23:401–19.

    PubMed  CAS  Google Scholar 

  24. Woloshin S, Bickell NA, Schwartz LM, et al. Language barriers in medicine in the United States. JAMA. 1995;273:724–8.

    Article  PubMed  CAS  Google Scholar 

  25. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care program. JAMA. 1999;281:545–51.

    Article  PubMed  CAS  Google Scholar 

  26. Perez-Stable EJ, Napoles-Springer A, Miramontes JM. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care. 1997;35:1212–9.

    Article  PubMed  CAS  Google Scholar 

  27. Piette JD. Moving diabetes management from clinic to community: development of a prototype based on automated voice messaging. Diabetes Educ. 1997;23:672–9.

    Article  PubMed  CAS  Google Scholar 

  28. Brislin RW, Lonner WJ, Thorndike EM. Cross-Cultural Research Methods. New York: Wiley; 1973.

    Google Scholar 

  29. Schwartz LM, Woloshin S, Wasson JH, Renfrew RA, Welch HG. Setting the revisit interval in primary care. J Gen Intern Med. 1999;14:230–5.

    Article  PubMed  CAS  Google Scholar 

  30. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. New Engl J Med. 1983;309:1426–34.

    Article  PubMed  CAS  Google Scholar 

  31. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal: does it affect health? New Engl J Med. 1984;311:480–4.

    Article  PubMed  CAS  Google Scholar 

  32. Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH. Termination from Medi-Cal benefits: a follow-up study one year later. New Engl J Med. 1986;314:1266–8.

    Article  PubMed  CAS  Google Scholar 

  33. Burgess JF, DeFiore DA. The effect of distance to VA facilities on the choice and level of utilization of VA outpatient services. Soc Sci Med. 1994;39:95–104.

    Article  PubMed  Google Scholar 

  34. Holloway JJ, Medendorp SV, Bromberg J. Risk factors for early readmission among veterans. Health Serv Res. 1990;25(1 Pt 2):213–7.

    PubMed  CAS  Google Scholar 

  35. Piette JD, Moos RH. The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction. Health Serv Res. 1996;31:573–91.

    PubMed  CAS  Google Scholar 

  36. Ahluwalia JS, McNagny SE, Rask KJ. Correlates of controlled hypertension in indigent, inner-city hypertensive patients. J Gen Intern Med. 1997;12:7–14.

    Article  PubMed  CAS  Google Scholar 

  37. Lederle FA, Parenti CM. Prescription drug costs as a reason for changing physicians. J Gen Intern Med. 1994;9:162–3.

    Article  PubMed  CAS  Google Scholar 

  38. Jain S, Avins AL, Mendelson T. Preventive health services and access to care for male veterans compared to their spouses. Western J Med. 1998;168:499–503.

    CAS  Google Scholar 

  39. Piette JD. Satisfaction with care among patients with diabetes in two public health care systems. Med Care. 1999;37:538–46.

    Article  PubMed  CAS  Google Scholar 

  40. Starfield B. Access—perceived or real, and to what? JAMA. 1995;274:346–7. Editorial.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park Division (152), 795 Willow Road, 94025, Menlo Park, CA

    John D. Piette PhD

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  1. John D. Piette PhD
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Correspondence to John D. Piette PhD.

Additional information

Received from the Center for Health Care Evaluation/HSR&D Center of Excellence, VA Palo Alto Health Care System, Palo Alto, Calif; and the Department of Health Research and Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, Calif.

The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs.

This research was supported by the Clinical Research Grants Program of the American Diabetes Association and by the Health Services Research and Development Service, the Quality Enhancement Research Initiative, and the Mental Health Strategic Healthcare Group of the Department of Veterans Affairs.

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Piette, J.D. Perceived access problems among patients with diabetes in two public systems of care. J GEN INTERN MED 15, 797–804 (2000). https://doi.org/10.1046/j.1525-1497.2000.91107.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.2000.91107.x

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