Failure to Utilize Diabetes Health Services Following a Referral

描述（由研究者提供）：该应用程序涉及广泛的挑战领域（01）行为、行为改变和预防以及具体的挑战主题，01-DK-103 提高对与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（例如标准实验室测试、专科就诊、健康教育）的模式和预测因素。鉴于疾病的复杂性、持续监测的需要以及频繁的强化，这些预防性卫生服务对于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尽管可以充分获得综合预付费医疗保健但仍不遵守糖尿病治疗计划的潜在高费用患者，并允许识别护理障碍。该项目使用 NIH 资助的研究北加州糖尿病研究 (DISTANCE) 的数据以及从 Kaiser Permanente 电子健康记录 (EHR) 获取的新数据。鉴于反复不使用（“持续不使用”）可能会对护理的连续性产生不利影响，并增加发生严重和昂贵事件的风险，该研究具有直接和长期的公共卫生影响。这项研究在挑战拨款的两年期限内是可行的。研究人员团队展示了生产力，结合了依从性和糖尿病健康服务研究方面的专业知识，并且在获取和分析所涉及的数据方面拥有丰富的经验。摘要 医疗治疗计划依从性差是糖尿病的一个严重的公共卫生问题。虽然依从性的某些方面，特别是对药物的依从性，已经得到了广泛的研究，但对于依从（利用）医疗服务转介（例如标准实验室测试、专科就诊、健康教育）的了解却少之又少。鉴于疾病的复杂性、持续监测的需要和频繁的强化，这些卫生服务对于糖尿病的护理至关重要。到目前为止，传统上是根据使用记录来评估护理质量和获得护理的机会。此类数据的一个重要限制是，它无法区分不使用的两种原因：1）医疗保健提供者没有提供护理（通过处方或转诊）与 2）不使用所提供的护理。虽然医疗保健提供者可能认为他们的患者在转诊后会使用医疗服务，但实际上不知道患者在多大程度上未能这样做。某些亚组，特别是少数群体和社会经济弱势患者的利用不足，很大程度上归因于获得医疗服务的社会差异，而不是所提供的护理利用不足（即依从性不足）。虽然需要资源来增加弱势群体的获取机会，但我们必须考虑到，即使在获取机会不存在问题的情况下，所提供的服务也没有得到最佳利用。在这项研究中，我们利用电子健康记录 (EHR) 系统，该系统在大型综合医疗保健服务系统 (Kaiser Permanente) 中捕获电子转诊和处方。 EHR 使我们能够调查未利用转介医疗服务的情况。鉴于反复不使用（“持续不使用”）可能会对护理的连续性产生不利影响，并增加严重的风险，这可能具有重大的公共卫生重要性。 以及代价高昂的事件。了解不使用和持续不使用的患病率、社会模式、患者、提供者和系统层面的预测因素将有助于设计旨在减少这种形式的不依从性的干预措施。研究结果还将为护理质量和获取机会提供更准确和有效的定义，并对我们理解护理质量的社会差异具有重要的应用。研究对象将包括北加州凯撒医疗机构糖尿病登记处的成员，该登记处是一个规模庞大、特征明确、种族多元化的受保糖尿病管理患者群体。社会弱势患者在本研究人群中得到了很好的体现，与大多数基于人群的样本不同，该人群获得的护理服务和质量相对统一。鉴于 92% 的美国人糖尿病患者拥有健康保险，这一受保人群的研究结果应该具有广泛的公共卫生相关性。此外，我们还将受益于 DISTANCE 队列中 20,188 名糖尿病患者提供的丰富的患者级别数据。鉴于这将是第一个评估不使用转诊护理的大型流行病学研究，它将更全面地了解不依从如何影响健康，并可能为未来旨在减少健康差异的干预措施的设计提供信息。我们有证据表明，一小部分纳入综合健康计划的糖尿病患者在转诊至承保医疗服务（例如标准实验室测试、专科就诊、健康教育）后未能利用护理服务。这些不使用的患者缺乏连续性的护理，发生不良事件的风险很高，并且最终可能比使用提供的护理的患者花费更多的医疗保健系统成本。 公共卫生相关性：在本研究中，我们将评估不利用和持续（反复）不利用糖尿病转诊医疗服务的普遍性。然后，我们将评估社会差异以及其他患者、提供者和系统层面的未利用预测因素。了解不使用将有助于旨在减少这种形式的不遵守的设计干预措施。研究结果还将为护理质量和获取机会提供更准确和有效的定义，并对我们理解护理质量的社会差异具有重要的应用价值。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“陷入困境”的患者，并允许医疗保健服务系统修改其计划以更好地为他们的会员服务。

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.