Continuity and quality of care in type 2 diabetes

,

Original Research

Continuity and quality of care in type 2 diabetes

J Fam Pract. 2002 July;51(7):619-624

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References

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Patient demographics are shown in Table 2 and are compared with the characteristics of the general adult patient population from a previous study (Sandra K. Burge, PhD, oral communication, December 2001). Most subjects were Hispanic, female, and married. Half of the sample had less than a high school education, and 36% had no health insurance. The mean Continuity and Quality of Care scores are also shown in Table 2. There were no significant differences in continuity scores across clinic sites, but 2 sites had significantly higher Quality of Care scores.

The first set of analyses compared quality of care between those who had (90.1%) and those who had not (9.9%) seen their usual providers in the past year. The overall quality of care score was significantly higher for patients who reported that they had seen their usual providers in the past year (73.0 vs 67.1, P = .038). The association between patients having seen their usual providers in the past year and each quality indicator is shown in Table 3. Patients who had seen their usual providers were significantly more likely to have had an eye examination, a foot examination, 2 blood pressure measurements, and a lipid analysis in the past year.

The second set of analyses examined the relation between the continuity or Usual Provider Continuity score and quality of care. A total of 214 subjects had complete chart and survey data that allowed for calculation of Continuity and quality of care scores. The overall quality of care score was associated significantly with the Usual Provider Continuity score in the hypothesized direction (r = .148, P = .03). As continuity improved, so did quality of care. In the 2-level multiple regression model, after adjusting for age, sex, education, total number of clinic visits, self-rated general health status, and clinic site, the relations between the Usual Provider Continuity score and the quality of care score remained significant (P = .03; Table 4). Total number of visits was not associated with the quality of care score.

TABLE 2
Characteristics of sample

Characteristic	Diabetic subjects	Adult clinic population
Mean (SD) age, y	56.15 (12.34)	41.4
% Female	68.2	74
% Hispanic	80.5	80
% Preferred Spanish survey	19.2	19
% Married	54.1	57.0
% Subjects with less than high school education	49.8	29
% Subjects without health insurance	36.6	31
Mean (SD) Usual Provider Continuity score	0.72 (0.31)	NA
Mean (SD) total visits	7.75 (6.32)	NA
Mean (SD) quality of care score	72.3 (14.3)	NA
NA, not available; SD, standard deviation.

TABLE 3
Association between individual quality indicators and a visit to usual provider in past year

	OR (CI)
HbA1c in past year?	1.76 (0.81–3.84)
Eye examination in past year?	1.99 (1.01–4.04)*
Foot examination in past year?	2.62 (1.27–5.41)*
Blood pressure reading twice in past year?	2.51 (1.07–5.94)*
Lipid test in past year?	4.11 (2.02–8.38)*
Urine protein in past year?	1.52 (0.76–3.05)
Self-management education in past year?	1.60 (0.75–3.43)
Diet education in past year?	1.04 (0.45–2.37)
Self-monitoring of glucose?	1.15 (0.52–2.56)
Tobacco status and counseling?	0.97 (0.38–2.46)
Very satisfied with
Diabetes care overall?	1.23 (0.54–2.81)
Diabetes questions answered?	1.32 (0.61–2.84)
Access during emergencies?	1.58 (0.69–3.61)
Explanation of laboratory results?	1.4 (0.55–3.90)
Courtesy/personal manner of provider?	1.46 (0.72–2.97)
*P < .05.
CI, 95% confidence interval; Hb, hemoglobin; OR, odds ratio.

TABLE 4
Regression model: continuity score and quality of care

Variable	Standardized beta	t	P
Age	.13	1.63	.10
Sex	.02	.21	.83
Education level	.11	1.37	.17
General health status	-.01	-.06	.95
Site A	.04	.52	.60
Site B	.20	2.25	.02
Site C	.18	2.01	.05
Site D	.03	.38	.71
Site E	-.02	-.20	.84
Total visits	.08	1.05	.30
Continuity score	.17	2.24	.03

Discussion

Patients who reported that they saw their regular providers in the past year had higher Quality of Care scores. Further, continuity of care received by diabetic patients was directly related to their overall quality of care. In a closer examination of the quality indicators, patients who reported that they had seen their usual providers within the past year were more likely to have received an eye examination, a foot examination, 2 blood pressure measurements, and a lipid analysis.

Why should continuity be associated with quality of care? Flocke and colleagues found that continuity was associated with accumulated knowledge of the patient by the physician as well as the coordination of care.¹⁴ These processes of care may have contributed to higher quality of care for patients with type 2 diabetes. The usual provider recognized the need for eye examinations and lipid measurements and coordinated these referrals. In another study, continuity was significantly related to patient adherence to advice about behavioral risk factors.¹⁰ In a similar fashion, continuity may have encouraged patient adherence to recommended screening tests such as referrals for eye examinations or returning for a fasting lipid measurement.

The lack of a relationship between the patients’ reports of seeing their usual providers within the past year and the other quality of care indicators is also of interest. Systems may have been established in those clinics to ensure delivery of those services regardless of whether or not patients are seen by their usual providers. For example, referral for diet education and self-monitoring of blood glucose may have been delegated to clinic staff. Some indicators, such as glycosylated hemoglobin, may be implemented at such high levels and with such low variability that there is not enough variation in the measure to detect any relation to continuity. Approximately 95% of our sample had a glycosylated hemoglobin measured within the past year on chart review.