Failure to Utilize Diabetes Health Services Following a Referral

转诊后未能利用糖尿病健康服务

• 批准号: 7935424
• 负责人: Andrew John Karter
• 金额: $ 24.66万
• 依托单位: KAISER FOUNDATION RESEARCH INSTITUTE
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-18 至 2011-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7935424
• 关键词: Address; Adherence; Adverse event; Affect; American; Appointment; Area; Attention; Award; Behavior; Behavioral; Blood Glucose Self-Monitoring; Blood Tests; California; Caring; Clinical; Consult; Continuity of Patient Care; Continuous Positive Airway Pressure; Data; Data Analyses; Diabetes Mellitus; Disadvantaged; Disease; Durable Medical Equipment; Education; Electronic Health Record; Electronics; Epidemiologic Studies; Ethnic Origin; Ethnic group; Event; Failure; Funding; Future; Grant; Health; Health Care Costs; Health Insurance; Health Personnel; Health Planning; Health Services; Health Services Accessibility; Health Services Research; Health behavior; Health education; Healthcare; Healthcare Systems; Income; Individual; Integrated Delivery of Health Care; Intervention; Link; Low income; Managed Care; Medical; Minority; Monitor; Nursing Care Management; Nutritionist; Ophthalmic examination and evaluation; Outcome; Patients; Pattern; Pharmaceutical Preparations; Policies; Population; Population Heterogeneity; Population Study; Prevalence; Prevention; Preventive Health Services; Primary Health Care; Process; Productivity; Provider; Public Health; Quality of Care; Records; Registries; Research Personnel; Resources; Respondent; Retinal; Risk; Risk Factors; Sampling; Self Management; Services; Sleep Apnea Syndromes; Specific qualifier value; Study Subject; Subgroup; Surveys; System; Testing; Time; United States National Institutes of Health; Urine; Visit; Vulnerable Populations; abstracting; base; cohort; cost; design; diabetes management; diabetic patient; experience; falls; health care delivery; health care quality; health care service utilization; health disparity; high risk; improved; medical specialties; medication compliance; member; population based; predictive modeling; programs; public health relevance; racial and ethnic; service utilization; smoking cessation; social; social disparities; socioeconomics; therapy design; treatment planning; uptake

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.

描述（调查人员提供）：此申请解决了广泛的挑战领域（01）行为，行为改变以及预防和特定挑战主题，01-DK-103改善了对与糖尿病患者不遵守的行为和社会因素的理解。我们建议研究糖尿病患者未能使用推荐健康服务的模式和预测因子（例如，标准实验室测试，专业访问，健康教育）。鉴于疾病的复杂性，持续监测的需求以及频繁的强化，这些预防性卫生服务在护理糖尿病方面尤为重要。该项目将为NIH重要的两个领域提供政策：（1）如何解决糖尿病患者的依从性不佳以及（2）如何减少健康差异。发现将帮助我们更好地了解，尽管完全获得综合，预付费的医疗保健并允许识别护理障碍，但他们不遵守其糖尿病治疗计划的潜在高成本患者。该项目使用NIH资助的研究，即北加州糖尿病研究（距离）以及从Kaiser Permanente电子健康记录（EHR）捕获的新数据。鉴于反复的非利用（“持续非利用化”）可能会对护理的连续性产生不利影响，并增加严重事件的风险，因此该研究具有直接和长期的公共卫生影响。这项研究是在挑战补助金奖的两年时间内可行的。研究者团队已经证明了生产力，结合了依从性和糖尿病健康服务研究的专业知识，并且在获取和分析所涉及的数据方面经验丰富。抽象对医疗计划的依从性不佳是糖尿病中严重的公共卫生问题。尽管已经对依从性的某些方面进行了广泛的研究，但对遵守（使用）卫生服务转诊（例如，标准实验室测试，专业访问，健康教育）的遵守知之甚少。鉴于疾病的复杂性，持续监测的需求以及频繁的强化，这些卫生服务对于护理糖尿病至关重要。到目前为止，传统上从利用记录中评估了质量和获得护理的质量。此类数据的一个重要限制是，它不能区分非利用的两个原因：1）医疗保健提供者没有提供（通过处方或转诊）与2）不利于所提供的护理的护理。尽管医疗保健提供者可能会认为他们的患者将在转诊后使用医疗服务，但实际上未知患者未能做到这一点。在某些亚组中的利用率不足，特别是在少数群体和社会经济处境不利的患者中，主要归因于获得的社会差异，而不是对所提供的护理的利用不足（即依从性不足）。尽管需要资源来增加弱势群体的访问权限，但我们必须考虑，即使没有访问权限，也可以在提供的服务中次优。在这项研究中，我们利用了电子健康记录（EHR）系统，该系统捕获了大型综合医疗保健提供系统（Kaiser Permanente）中的电子转介和处方。 EHR使我们能够调查推荐卫生服务的非利用化。鉴于反复的非利用（“持续非利用”）可能会对护理的连续性产生不利影响，并增加严重的风险 和昂贵的事件。了解非利用化和持续性非利用的患病率，社会模式，患者，提供者和系统级别的预测指标将允许设计旨在降低这种不遵守形式的干预措施。调查结果还将为护理和获取质量的更准确，更有效的定义提供信息，并为我们理解护理质量的社会差异提供重要的应用。研究对象将包括Kaiser Permanente North California糖尿病注册中心的成员，该注册表是一个大型，良好的，种族良好的，多样化的，有保险人群的糖尿病患者，糖尿病患者。与大多数基于人群的样本不同，在这项研究人群中，社会不利的患者在这项研究人群中有很好的代表性，该研究人群相对均匀地获得护理和质量。鉴于有92％的糖尿病美国人拥有健康保险，因此被保险人群的调查结果应具有广泛的公共卫生相关性。此外，我们将受益于远距离队列中20188名糖尿病患者提供的丰富患者级数据。鉴于这将是评估不利用转诊护理的第一项大型流行病学研究，它将对非依从性如何影响健康的方式提供更全面的理解，并可能为旨在减少健康差异的未来干预措施提供信息。我们有证据表明，在综合健康计划中，一小部分糖尿病患者在推荐覆盖的健康服务后无法使用护理（例如，标准实验室测试，专业访问，健康教育）。这些非利用的患者缺乏连续的护理，面临不良事件的高风险，并且最终可能比利用提供护理的患者付出更多的代价。 公共卫生相关性：在本研究中，我们将评估非利用和持续性（重复）不利于糖尿病的卫生服务的普遍性。然后，我们将评估社会差异和其他患者，提供者和系统级别的非利用化预测指标。了解非利用将有助于降低这种不遵守形式的设计干预措施。调查结果还将为护理和获取质量的更准确，更有效的定义提供信息，并为我们了解护理质量的社会差异而具有重要的应用。该项目将帮助我们更好地了解，尽管完全获得综合医疗保健，但仍“陷入裂缝”的患者，并允许医疗保健服务系统修改其计划以更好地服务其会员资格。