Encounters by Patients With Type 2 Diabetes--Complex and Demanding: An Observational Study

Abstract

PURPOSE We wanted to examine the relationships between quality of diabetes care delivered, the type and length of encounter, and time to the next follow-up encounter. METHODSThe content of the physician-patient encounter was directly observed in 20 primary care clinics for 211 patients with type 2 diabetes mellitus. The quality of diabetes care was measured as the percentage of the 5 following services delivered during the encounter if they had not been offered in the previous year: foot examination, referral for an eye examination, a glycosylated hemoglobin (HbA 1c ) measurement, a lipid panel, and a urine microalbumin test. RESULTSAll indicated services were performed in 33% of encounters. Compared with encounters for an acute illness, patients visiting for chronic disease followup were 4.8 (95% CI, 1.95%-12.01%) times more likely to receive 100% of all indicated services. Length of encounter was associated with percentage of services delivered, but only during chronic disease follow-up encounters (P = .02). Encounters during which 100% of all indicated services were delivered had a mean length of 19.4 minutes. The time to the next scheduled encounter was shorter if fewer services were delivered during the observed encounter (P = .009). CONCLUSIONSCompeting demands during primary care encounters require patient and physician to prioritize services delivered and defer indicated services to subsequent visits. Current models of patient care in primary care settings are inadequate to address the multitude of tasks facing clinicians, especially among patients with complex chronic illnesses. Innovative approaches and new models are needed to improve the quality of diabetes care.

An Assessment of Attitudes, Behaviors, and Outcomes of Patients with Type 2 Diabetes

“…2 Factors contributing to poor control include inadequacies in patient self-care behaviors, medical management, or both. [3][4][5][6][7] Physicians know that patient self-care behaviors influence diabetes control but may lack training for and interest in motivating their patients to improve these behaviors. 8 Contributing to poor control is a paucity of information available about the frequency of problem behaviors, barriers to appropriate care behaviors, or the relationship of specific patient self-care behaviors to glycemic control.…”

The Chronic Care Model and Exercise Discussions during Primary Care Diabetes Encounters

“…Moreover, the competing demands of managing chronic conditions in older patients during the scheduled visit time may preclude addressing other issues such as health promotion. 4,13,39 Why should the presence of the CCM be related to length of discussion about exercise? It is possible that higher CCM scores reflect a more proactive approach to improving exercise.…”

“…5,13,17 Details of the methods have been explained in previous studies. 7,8 The data were collected as part of an in-depth examination of the of quality of care delivered to patients with type 2 diabetes across a wide variety of primary care settings in 2002 to 2003.…”

“…We found that patients in clinics with high CCM scores were more likely to be in the maintenance SOC for exercise and other self-care behaviors. 3,5,7,8,[13][14][15][16][17] One possible explanation for this relationship is that in clinics with higher CCM scores patients receive more advice and support to improve their level of exercise.…”

The Gordian Knot of Chronic Illness Care

“…7 Given that the average patient with diabetes seen in family physician offices is on more than 6 oral medications, and that good blood pressure control in the United Kingdom Prospective Diabetes Study required an average of 3 or more antihypertensive medications, who among us has not encountered the patient who complains that they are already on too many medications when we suggest that another medication is needed to achieve adequate blood pressure control. 8,9 The study by Shani et al 10 seems to suggest that the physician caring for the patient with diabetes is an important predictor of good glucose control, but none of the measured physician characteristics were significant predictors. Furthermore, clinic size was an important predictor, with a higher propor- tion of patients seen in intermediate-size clinics under good control.…”