Quality of preventive care for diabetes: Effects of visit frequency and competing demands

PURPOSE We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List. METHODS We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association-recommended preventive services, including regular hemoglobin A(1c) (HbA(1c)) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise. RESULTS After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA(1c) test (odds ratio [OR] = 0.35, 95% confidence interval [C1], 0.24-0.51), retinal examination (OR = 0.74, 95% CI, 0.63-0,86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58-0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least I HbA(1c) test (OR = 0.59, 95% CI, 0.35-1.01), retinal examination (OR = 0.68, 95% CI, 0.56-0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57-1.09) despite attending a similar mean number of total visits as higher-priority users. CONCLUSIONS Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.