Failure to Utilize Diabetes Health Services Following a Referral

描述（由研究者提供）：该申请解决了广泛的挑战领域（01）行为、行为改变和预防以及特定的挑战主题，01- dk -103提高了对糖尿病患者不依从性相关的行为和社会因素的理解。我们建议研究糖尿病患者未能利用转诊医疗服务（如标准实验室检查、专科就诊、健康教育）的模式和预测因素。鉴于糖尿病的复杂性、需要持续监测和频繁强化，这些预防性保健服务对糖尿病的护理尤为重要。该项目将为NIH的两个重要领域的政策提供信息：(1)如何解决糖尿病患者依从性差的问题；(2)如何减少健康差距。研究结果将帮助我们更好地了解那些尽管完全可以获得综合、预付费的医疗保健，但却不坚持糖尿病治疗计划的潜在高成本患者，并允许识别护理障碍。该项目使用的数据来自美国国立卫生研究院资助的一项研究——北加州糖尿病研究（DISTANCE），以及从凯撒医疗机构电子健康记录（EHR）中获取的新数据。鉴于反复不使用（“持续不使用”）可能对护理的连续性产生不利影响，并增加发生严重和代价高昂事件的风险，该研究具有直接和长期的公共卫生影响。这项研究在两年的时间框架内是可行的。研究小组已显示出生产力，结合了依从性和糖尿病卫生服务研究方面的专业知识，并在获取和分析相关数据方面经验丰富。糖尿病患者对药物治疗方案的依从性差是一个严重的公共卫生问题。虽然对坚持服药的某些方面，特别是坚持服药的情况进行了广泛的研究，但对坚持（利用）转诊的情况（例如，标准实验室检查、专科就诊、健康教育）所知甚少。鉴于糖尿病的复杂性、需要持续监测和频繁强化，这些卫生服务对糖尿病的护理至关重要。到目前为止，传统上一直是根据利用记录来评估保健的质量和可及性。此类数据的一个重要限制是，它不能区分不利用的两种原因：1)医疗保健提供者未提供护理（通过处方或转诊）与2)未利用所提供的护理。虽然医疗保健提供者可能假设他们的病人在转诊后会使用医疗服务，但实际上不知道病人在多大程度上没有这样做。在某些亚群中，特别是在少数民族和社会经济上处于不利地位的患者中，利用不足主要归因于可获得性方面的社会差异，而不是所提供护理的利用不足（即依从性不足）。虽然需要资源来增加弱势群体获得服务的机会，但我们必须考虑到，即使在获取服务没有问题的情况下，所提供服务的接受程度也不理想。在本研究中，我们利用电子健康记录（EHR）系统，该系统在大型综合医疗服务系统（Kaiser Permanente）中捕获电子转诊和处方。电子病历使我们能够调查未利用转诊保健服务的情况。鉴于反复不使用（“持续不使用”）可能对护理的连续性产生不利影响，并增加严重疾病的风险，这可能具有重大的公共卫生重要性

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.