OBJECTIVE: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities.
STUDY DESIGN: We performed a retrospective analysis of claims data captured by the Medicare program.
POPULATION: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994.
OUTCOME MEASURES: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination.
RESULTS: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests.
CONCLUSIONS: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate—but not excessive—supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.
It is difficult to provide high-quality care to elderly patients with diabetes, and this task may be even more problematic in rural areas.1 There are fewer physicians in such areas, and chronic conditions may get short shrift from both physicians and patients.2 The relative shortage of specialists in rural areas may make it more difficult for physicians and their patients to get some of the specialized services they may need.3 Knowledge about advances in diabetic care may diffuse more slowly to these areas, making it less likely that physicians and patients will be aware of or adhere to published guidelines.
Previous studies have shown that the rural elderly-particularly those living in the smallest and most remote areas-make fewer office visits to physicians.2 These same patients are more likely to see family physicians-and less likely to visit specialists-than their urban counterparts.4 It is not known whether this is true specifically of patients with diabetes, and the impact of these patterns on adherence to generally accepted guidelines is unknown.
We examined rural-urban differences in the care of persons with diabetes to determine what kinds of locations promote high-quality care. It may be possible to improve diabetes care either through further training of generalists or by providing opportunities for formal consultation with relevant specialists within the communities where these patients live.
Methods
Our study was based on data from the Medicare program for Washington state in 1994. During that year 362,145 Medicare recipients 65 years and older used medical care, did not belong to a capitated plan, had continuous Medicare coverage, received all their medical care in Washington State, and were alive at the end of the year.
For the purposes of our study, a diabetic visit is defined as any visit to a physician in an ambulatory setting where that physician entered any of the following International Classification of Diseases–ninth revision codes as a diagnosis: 250.XX (diabetes), 362.01 and 262.02 (diabetic retinopathy), 357.2 (diabetic polyneuropathy), or 366.41 (diabetic cataract). Patients are considered to have diabetes if they have at least 2 physician encounters for 1 of these codes in an ambulatory setting on separate days.
Patient residence was determined by the residential ZIP Code, and all patients were assigned as being rural or urban based on their residence.5 Rural communities were considered to be large if they had hospitals with more than 100 beds. The identity of the physician was determined from the unique physician identification number (UPIN) assigned by Medicare. UPINs were present 99.1% of the time, and specialty could be determined for 99.0% of these physicians.
Quality of Care Measurements
We created a core quality index of items that most authoritative sources agree should be performed regularly in patients with diabetes6-9 and that can be identified using the Medicare Part B claims file.10-12 The core quality index included a glycated hemoglobin determination, cholesterol measurement, and an eye examination by either an ophthalmologist or an optometrist. A service was considered to have been performed if a claim for any of the above items-or for a multi-test procedure of which that item is a part-was submitted by any provider during the 1994 study year.
Analytic Approach
We used the ambulatory care group (ACG) case-mix classification system to control for patient comorbidities.13,14 Confidence intervals were calculated for independent and control variables in the logistic regression. Chi-square tests were used to compare results across different geographic areas. Because of multiple comparisons, we only report differences significant at the .01 level.