Impact of primary care on hospital admission rates for diabetes patients: A systematic review

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BACKGROUND

Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.

METHODS

We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.

RESULTS

Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.

CONCLUSIONS

Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Providing family planning counseling services for women with chronic medical conditions in an inpatient setting: A randomized feasibility trial

OBJECTIVES

This study aimed to evaluate the feasibility and effectiveness of providing bedside family planning services to women with chronic medical conditions in the inpatient setting.

STUDY DESIGN

We initiated a parallel randomized controlled trial of patients listed as female aged 18 to 44 years who were admitted to the hospital from February 2018 to May 2021 with at least one chronic medical condition associated with lower rates of contraception usage and no documentation of contraception. Patients who confirmed they were not using contraception were enrolled and randomized to one of the three arms. They received bedside family planning counseling and an offer of contraception prior to discharge (oral contraceptive pills, etonogestrel implant, or medroxyprogesterone injection), received a flyer recommending they talk with their outpatient physician about contraception, or received standard care. The primary outcomes were contraception use at 3 months and 12 months after discharge.

RESULTS

Altogether 76 subjects were enrolled and randomized with 22 in the counseling arm and 27 each in the other arms. In the counseling arm, five (23%; 95% CI: 8.0%-45%) elected to receive contraception prior to discharge. Inferential statistics at follow-up were not able to be calculated due to high attrition.

CONCLUSIONS

Providing counseling and offering immediate contraception initiation in the inpatient setting may be a feasible approach to improving contraception access for this population. Additional investigation into the acceptability, efficacy, and generalizability of this approach is warranted.

IMPLICATIONS

Utilizing the inpatient setting may be a feasible approach for delivering contraception counseling to women with chronic medical conditions. This approach merits further study for effectiveness and acceptability. This study highlights the need for contraceptive counseling and initiation to become a standard part of hospital care for pregnancy-capable individuals.

How does the quality of care for type 2 diabetic patients benefit from GPs-nurses' teamwork? A staggered difference-in-differences design based on a French pilot program

In many countries, policies have explicitly encouraged primary care teams and inter-professional cooperation and skill mix, as a way to improve both productive efficiency gains and quality improvement. France faces barriers to developing team working as well as new and more advanced roles for health care professionals including nurses. We aim to estimate the impact of a national pilot experiment of teamwork between general practitioners (GPs) and advance practitioners nurses (APN)-who substitute and complement GPs-on yearly quality of care process indicators for type two diabetes patients (T2DP). Implemented by a not-for-profit meso-tier organisation and supported by the Ministry of Health, the pilot relied on the voluntary enrolment of newly GPs from 2012 to 2015; the staffing and training of APNs; skill mixing and new remuneration schemes. We use latent-response formulation models, control for endogeneity and selection bias by using controlled before-after and quasi-experimental design combining coarsened exact matching-prior to the treatment, at both GPs (435 treated vs 973 control) and T2DP levels -, with intention to treat (ITT; 18,310 in each group) and per protocol (PP, 2943 in each group) perspectives, as well as difference-in-differences estimates on balanced panel claims data from the National Health Insurance Fund linked to clinical data over the period 2010-2017. We show evidence of a positive and significant positive impact for T2DP followed-up by newly enrolled GPs in the pilot compared to the pretreatment period and the control group. The effect magnitudes were larger for PP than for ITT subsamples.

Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis

BACKGROUND

Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care.

METHODS

Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models.

RESULTS

Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16).

INTERPRETATION

Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.

Why are there so many hospital beds in Germany?

The place of hospitals in health systems is undergoing rapid change worldwide due to the high cost of hospital care and the changing health needs of the population. The Covid-19 pandemic has recently drawn public attention towards hospital capacity and has added new urgency to discussions on the future role of hospitals. In this context, recent experience in Germany provides valuable information for health systems seeking to manage hospital capacity. Despite reform efforts to reduce hospital capacity, Germany has the highest rates of intensive care beds among high-income countries and the highest overall hospital capacity in Europe. The capacity of the German hospital system can be explained in large part by the high number of elderly in-patients. This, in turn, is driven by (1) a fragmented ambulatory care system; (2) physicians admitting and maintaining elderly patients in hospital at a high rate; (3) a hospital market adding incentives to admit patients; and (4) a political commitment to egalitarian access and universal care. Additionally, recent policies to reduce hospital capacity have had limited impact because hospitals have not responded to financial incentives in the expected manner. Countries looking to learn from Germany's hospital capacity must therefore consider systemic features, political commitments, and unintended policy consequences.

Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China

BACKGROUND

Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation.

METHODS

In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis.

RESULTS

Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs.

CONCLUSION

The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.

Inequalities in glycemic and multifactorial cardiovascular control of type 2 diabetes: The Heart Healthy Hoods study

Aim

This study aimed to analyze glycemic control and multifactorial cardiovascular control targets in people with type 2 diabetes (T2DM) in primary care according to sex and socioeconomic status (SES).

Materials and methods

This is an observational, cross-sectional, and multicenter study. We analyzed all the patients with T2DMM aged between 40 and 75 years in Madrid city (113,265) through electronic health records from 01 August 2017 to 31 July 2018. SES was defined by an area-level socioeconomic index stratified by quintiles (1st quintile: more affluent).

Outcomes

Outcomes included glycemic control (HbA1c ≤ 7%), 3-factor cardiovascular control [HbA1c ≤ 7%, blood pressure (BP), < 140/90 mmHg, LDL < 100 mg/ml] and 4-factor control [HbA1c ≤ 7%, blood pressure (BP) < 140/90 mmHg, LDL < 100 mg/ml, and BMI < 30 kg/m²]. Multilevel logistic regression models analyzed factors associated with suboptimal glycemic control.

Results

In total 43.2% were women. Glycemic control was achieved by 63% of patients (women: 64.2% vs. men: 62.4%). Being more deprived was associated with suboptimal glycemic control (OR: 1.20, 95% CI: 1.10-1.32); however, sex was not related (OR: 0.97, 95% CI: 0.94-1.01). The optimal 3-factor control target was reached by 10.3% of patients (women: 9.3% vs. men: 11.2%), especially those in the 5th quintile of SES. The 4-factor control was achieved by 6.6% of the sample. In the 3-factor control target, being women was related to the suboptimal 3-factor control target (OR: 1.26, 95% CI: 1.19- 1.34) but only belonging to SES 4th quintile was related to the unachieved target (OR: 1.47, 95% CI: 1.04-2.07).

Conclusion

Suboptimal glycemic control was associated with being less affluent and suboptimal 3-factor control target was associated with being women.

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Inequalities in care for the people with diabetes in Brazil: A nationwide study, 2019

The purpose of this paper is to evaluate inequalities in care for people with diabetes in Brazil. This cross-sectional population-based study was carried out in 2019 and evaluated care provided by receiving advice, requesting laboratory tests, and performing examinations. We used the slope index of inequality and concentration index to assess inequalities according to educational level and Poisson regression to estimate prevalence ratios for each outcome in the education category. We assessed a total of 6317 people with diabetes, 41.8% had their eyes checked, and 36.1% had their feet examined in the previous year. Prevalence for both examinations was 2.45 times higher in those from the highest level of education compared to those from the lowest level. The largest absolute differences (in percentage points) between the lowest and highest education levels in care indicators were the following: request for glycated hemoglobin test (39.0), glucose curve test (31.4), and eyes checked in the previous year (29.7). There were notable inequalities in the prevalence ratios of care provided to people with diabetes in Brazil. Requests for glycated hemoglobin tests, glucose curve tests, eye and feet examinations should be emphasized, especially for people from lower educational levels.

Self-care practices and correlates among patients with type 2 diabetes in Eastern Ethiopia: A hospital-based cross-sectional study

Objective:

This study investigated the level and correlates of self-care practices among patients with type 2 diabetes on follow-up in two public hospitals in Harar, Eastern Ethiopia.

Methods:

We conducted a hospital-based cross-sectional study on adult patients with type 2 diabetes, surveying diabetes self-care practices using a 15-item Summary of Diabetes Self-Care Activities. Responses ranged from 0 to 7 days, and a composite score was computed representing the mean days of diabetes self-care practices. A generalized Poisson regression model with robust variance was used. The association between the diabetes self-care practices and correlates was examined using the incidence rate ratio with a 95% confidence level. The statistical significance was set at a p value of ⩽0.05.

Results:

This study included 879 patients with type 2 diabetes. The overall mean (standard deviation) diabetes self-care practices were 3.7 ± 1.1 days out of the recommended 7 days, indicating low self-care practices. After controlling for other variables, tertiary educational level (incidence rate ratio = 1.06; 95% confidence interval: 1.01, 1.12), adequate diabetes knowledge (incidence rate ratio = 1.04; 95% confidence interval: 1.00, 1.08), moderate (incidence rate ratio = 1.07; 95% confidence interval: 1.02, 1.11) and high perceived self-efficacy (incidence rate ratio = 1.14; 95% confidence interval: 1.09, 1.13) (incidence rate ratio = 1.07; 95% confidence interval: 1.02, 1.11), high to marginal food security (incidence rate ratio = 1.13; 95% confidence interval: 1.03, 1.24), and receiving dietary advice (incidence rate ratio = 1.11; 95% confidence interval: 0.06, 1.15) were positively correlated with diabetes self-care practices. A history of hospitalization, on the other hand, was found to be inversely correlated with diabetes self-care practices (incidence rate ratio = 0.94; 95% confidence interval: 0.88, 0.99).

Conclusion:

The study indicated that adherence of patients with type 2 diabetes to the recommended self-care practices was considerably low. Therefore, tailored diabetes self-management education to enhance self-efficacy and diabetes self-care practices must be in place. This can be achieved through the system or individual-based integrated intervention efforts.

High-frequency HbA1c testing among older patients with diabetes in Japan: a longitudinal analysis using medical claims data

Aims

We aimed to determine the rate of high-frequency HbA1c testing among older Japanese patients (≥ 75 years) with type 2 diabetes who did not have diabetic complications and were not using insulin, and to explore its influencing factors and association with the number of hospital admissions.

Methods

A retrospective, longitudinal observation study design based on medical claims data between 2015 and 2020 was adopted. We tracked patients for 3 years to describe the annual rate and determine factors associated with high-frequency HbA1c testing using a hierarchical logistical model. We employed a zero-inflated Poisson model to examine the association between frequency of HbA1c testing and the number of hospitalizations.

Results

Among 6594 patients included (mean age 80.4 years), the rates of high-frequency HbA1c testing in the first, second, and third year were 10.2%, 4.8%, and 4.7%, respectively. Follow-up year [odds ratio (OR) = 0.54, 95% confidence interval (CI) = 0.49-0.59];insulin use (OR = 1.63, 95% CI = 1.26-2.11); multi facility for HbA1c testing (OR = 5.51, 95% CI = 4.66-6.51); more than 48 outpatient days per year (OR = 2.13, 95% CI = 1.81-2.51); hospitalizations (OR = 0.66, 95% CI = 0.55-0.79); two or more classes of antidiabetic agents at baseline (OR = 1.32, 95% CI = 1.11-1.56); and dementia at baseline (OR = 0.70, 95% CI = 0.51-0.97) were significantly associated with high-frequency HbA1c testing. No significant association between frequent HbA1c testing and the number of all-cause hospitalizations was found.

Conclusions

We revealed a high rate of HbA1c testing among older Japanese patients with type 2 diabetes in ambulatory care and indicated that high-frequency HbA1c testing was more likely to result from the decentralized healthcare system and its structure.

Individual and Combined Effect of Diabetes and Lifetime Criminal Justice Involvement on Healthcare Utilization in US Adults, 2015-2019

BACKGROUND

Diabetes and criminal justice involvement (CJI) are both associated with poor health outcomes and increased healthcare utilization. However, little is known about the additive effects of these risk factors when combined. This study examined the individual and combined effects of diabetes and CJI on healthcare utilization.

METHODS

Data from the National Survey of Drug Use and Health (2015-2019) was used to create a cross-sectional, nationally representative sample of US adults with diabetes, CJI, combination of both, or neither. Negative binomial regression was used to test the association between those with CJI and diabetes (compared to diabetes alone) and three utilization types (outpatient, ED, and inpatient) controlling for relevant sociodemographic and clinical covariates.

RESULTS

Of 212,079 respondents, representing 268,893,642 US adults, 8.8% report having diabetes alone, 15.2% report having CJI alone, and 1.8 % report both diabetes and lifetime CJI. After adjustment, those with diabetes and CJI had increased acute care utilization compared to those with diabetes alone (ED visits: IRR 1.13; 95% CI 1.00-1.28; nights hospitalized: IRR 1.34; 95% CI 1.08-1.67). There was no difference in outpatient utilization between those with both diabetes and CJI compared to those with diabetes alone (IRR 1.04, 95% CI 0.99-1.10).

CONCLUSION

Individuals with complex social and health risks such as diabetes and lifetime CJI experience increased acute healthcare utilization but no difference in outpatient utilization. Tailored interventions that target both diabetes and CJI are needed to reduce unnecessary utilization in this population.

Factors associated with long intensive care unit (ICU) admission among inpatients with and without diabetes in South Western Sydney public hospitals using the New South Wales admission patient data collection (2014-2017)

BACKGROUND

Long stay in intensive care unit (ICU) is associated with poor outcomes, particularly in people with diabetes. It increases the financial burden of care and this is a challenge to the South Western Sydney region, which is already a hotspot for diabetes in Australia. This study compared ICU admission characteristics of people with and without diabetes and the factors associated with long ICU stay among patients admitted to public hospitals in this metropolitan health district from 2014 to 2017.

METHODS

Cross-sectional datasets on 187,660, including all ICU admissions in the New South Wales Admitted Patient Data Collection (APDC) from June 2014 - July 2017 in public hospital were extracted. Data on demographic and health insurance status, primary admission diagnosis using ICD-10, comorbidities including death among hospital inpatients aged ≥18 years residing in SWS were analysed. The ICU length of stay was the outcome variable and were classified into short stay (≤48 h) and long stay (> 48 h), and were examined against potential confounding factors using bivariate and multiple logistic regression analyses.

RESULTS

Our results showed higher ICU admissions in patients with diabetes than in those without diabetes (5% vs. 3.3%, P < 0.001) over three years. The median and interquartile range (IQR) of length of the ICU stay were similar in both groups [diabetes: 40 h, IQR = 16-88 h vs. non-diabetes: 43 h, IQR = 19-79 h]. The prevalence of long ICU stays among people with and without diabetes were 44.9% [95% CI 42.1, 47.7%] and 43.6% [95% CI 42.2, 44.9%], respectively. For both groups, increased odds of long ICU stay were associated with death and circulatory system disease admissions, while musculoskeletal disease admissions were associated with lower risk of long ICU stay. In the non-diabetes group, male sex, nervous system disease admissions and living in peri-urban areas were associated with higher odds of long ICU stay.

CONCLUSIONS

The rate of ICU admissions among inpatients remain higher in people with diabetes. One in every two admissions to ICU had a long stay. Additional care for those admitted with circulatory system diseases are needed to reduce long ICU stay related deaths in SWS.

Dietary quality, food security and glycemic control among adults with diabetes

BACKGROUND AND AIMS

Nutritionally adequate diets can slow the progression of diabetes, but adherence to recommended dietary choices can be hindered by food insecurity. We examined the relationship between dietary quality, food insecurity, and glycemic control among adults with Type 2 Diabetes.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (2011-2016) for 1682 adults =>20 years old with Type 2 diabetes. Glycemic control was measured by HbA1c. Dietary quality was computed using the Healthy Eating Index 2015 score. Food security was assessed by a questionnaire. We analyzed the data using multinomial regression models.

RESULTS

About 16% of the population had an HbA1c ≥ 9; 31.8% had food insecurity; 68.3% consumed a poor quality diet. About 24% consumed a poor quality diet and had food insecurity. In the multinomial model, an HbA1c of 8-<9% was associated with poor diet quality (adjusted odds ratio (AOR) = 5.2, 95% confidence interval (CI) = 1.4-19.2, p = 0.01) and food insecurity (AOR = 8.5, 95% CI = 1.4-52.0, p = 0.02). Those with both factors had higher odds of both an HbA1c 8-<9% (AOR = 6.1, 95% CI = 1.5-24.8, p = 0.01) and HbA1c ≥ 9% (AOR = 6.7, 95% CI = 2.0-22.2, p < 0.01). Other risk factors for poor glycemic control were being Black or Hispanic, having no regular source of care, and ever having visited a diabetes specialist (p < 0.05).

CONCLUSIONS

Poor glycemic control among adults with diabetes was associated with poor quality of diet and/or food insecurity, being Black, Hispanic, and lacking a regular source of care. There is a need for policies that improve access to healthy food in patients with type 2 diabetes, particularly among minority populations.

The effect of primary care policy changes on hospitalisation for ambulatory care sensitive conditions: notes from Brazil

OBJECTIVES

The aim of this study was to assess the effect of the Primary Health Care Reform and the impact of recent national policy changes on the trend in hospitalisation rates for Ambulatory Conditions Sensitive to Primary Care (ACSC) in the city of Rio de Janeiro, Brazil.

STUDY DESIGN

Ecological study with data from the Brazilian National Health Information System.

METHODS

This study performed an interrupted time-series analysis, comparing three different time periods related to important changes in primary care policies in Brazil: Baseline (2008-2009); Primary Health Care Reform (RCAPS) (2010-2017); and National Primary Health Care Policy (PNAB) (2018-2019). Data included total monthly admissions for ACSC and rates for 19 groups of causes for hospitalisation.

RESULTS

There was a non-significant increasing trend in ACSC hospital admissions between January 2008 and December 2009 (β = 4.01, 95% confidence interval [CI] -12.14 to 20.15). The Primary Health Care Reform (RCAPS), which commenced in January 2010, resulted in a significant reduction in ACSC hospital admission trends during this time period (β = -7.97, 95% CI -9.78 to -6.16). Change in the PNAB did not change the declining ACSC hospital admission trend but it did reduce the rate of decline. In addition, the coefficient was no longer significant (β = -1.93, 95% CI -2.46 to 0.59), suggesting that monitoring of the historical series for a long time may show a reversal of the downward trend in some months. The most consistent change in ACSC hospital admission trend occurred between baseline and the RCAPS (β slope = -0.143, P < 0.001) and the level between the RCAPS period and the new PNAB (β step = 7.00, P = 0.008). Trends and differences in the time periods vary in the different ACSC hospitalisation-cause groups.

CONCLUSION

Changes in public health policies impact ACSC hospitalisation rates, which can thus be used as an indicator for monitoring primary health care. We also recommend analysing admission rates by the individual ACSC hospitalisation-cause groups.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

BACKGROUND

People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.

AIM

To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.

DESIGN & SETTING

Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).

METHOD

Factors precipitating admissions were examined using framework analysis.

RESULTS

Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.

CONCLUSION

Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Continuity in general practice and hospitalization patterns: an observational study

BACKGROUND

High continuity of care is a key feature of strong general practice. This study aimed to assess the effect of a programme for enhancing strong general practice care on the continuity of care in Germany. The second aim was to assess the effect of continuity of care on hospitalization patterns.

METHODS

We performed an observational study in Germany, involving patients who received a strong general practice care programme (n=1.037.075) and patients who did not receive this programme (n=723.127) in the year 2017. We extracted data from a health insurance database. The cohorts were compared with respect to three measures of continuity of care (Usual Provider Index, Herfindahl Index, and the Sequential Continuity Index), adjusted for patient characteristics. The effects of continuity in general practice on the rates of hospitalization, rehospitalization, and avoidable hospitalization were examined in multiple regression analyses.

RESULTS

Compared to the control cohort, continuity in general practice was higher in patients who received the programme (continuity measures were 12.47 to 23.76% higher, P< 0.0001). Higher continuity of care was independently associated with lowered risk of hospitalization, rehospitalization, and avoidable hospitalization (relative risk reductions between 2.45 and 9.74%, P< 0.0001). Higher age, female sex, higher morbidity (Charlson-index), and home-dwelling status (not nursing home) were associated with higher rates of hospitalization.

CONCLUSION

Higher continuity of care may be one of the mechanisms underlying lower hospitalization rates in patients who received strong general practice care, but further research is needed to examine the causality underlying the associations.

Assessing the quality of primary healthcare for diabetes in China: multivariate analysis using the China Health and Retirement Longitudinal Study (CHARLS) Database

OBJECTIVE

To assess the quality of primary healthcare (PHC) for patients with diabetes in China from 2011 to 2015.

SETTING

This study analysed data on 1006, 1472 and 1771 participants with diabetes who were surveyed in 2011, 2013 and 2015, respectively, in the China Health and Retirement Longitudinal Study, a nationally representative survey conducted in 29 provinces of China.

OUTCOME MEASURES

The study measured the proportions of patients with diabetes who received diabetes-related health education, examinations and treatments, as well as the hospital admission rate due to diabetes of these patients. Multilevel logistic regression was used to adjust sociodemographic variables.

RESULTS

According to the multivariate analysis, the proportion of patients who received diabetes-related health education decreased significantly (OR=0.74, 95% CI 0.61 to 0.90), and the proportion of those receiving examinations and treatments remained unchanged from 2011 to 2015. Diabetes-related hospitalisation increased from 4.01% in 2011 to 6.08% in 2013 (OR=1.47, 95% CI 0.97 to 2.22), and recurrent hospitalisations increased from 18.87% in 2011 to 28.45% in 2015 (OR=1.78, 95% CI 1.44 to 2.20). The proportions of patients with diabetes-related and recurrent hospitalisations in western China were higher than those in the east (OR=1.80, 95% CI 1.13 to 2.87; OR=1.92, 95% CI 1.50 to 2.45).

CONCLUSIONS

Nationally, the analysis of patient-reported process and outcome indicators cannot confirm that the quality of PHC has improved in China during 2011-2015. Regional disparities in primary diabetes care require urgent resource allocation to western China. Establishing a national quality registry for PHC, which transparently reports outcomes by region and social-economic position, is essential for countries sharing the challenge of improving both quality and equity of PHC.

Diagnosis and Treatment of Chronic Medical Conditions Among Trauma Patients at a Level 1 Trauma Center

Diabetes mellitus (DM) and hypertension (HTN) are increasing in prevalence in the population. Level 1 trauma facilities are often faced with managing these chronic conditions. Recent studies indicated that 12-44% of patients presenting traumas are found to have incidental findings by imaging representing undiagnosed medical conditions, with 10% reported requiring further management [Surendran A, Mori A, Varma DK, Gruen RL. Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: Are we getting the whole picture? J Trauma and Acute Care Surg. 2014;76(4):1122-1130]. Between 2015 and 2016, 852 patients seen at a level 1 trauma center were analyzed. Patients were evaluated who received a new diagnosis of HTN or DM, or had preexisting diagnosis of HTN or DM whose management was changed. Uncontrolled HTN or DM was defined as a need for either a change in medication or primary care optimization prior to discharge. Among the patients evaluated, 6.3% and 3.0% received new diagnoses of HTN and DM, respectively. Additionally, 34.4% and 35.3% of patients were found to have uncontrolled HTN and DM and required medical optimization, respectively. The high prevalence of undiagnosed or suboptimal management for chronic conditions indicates that more research is warranted for defining, screening for, and treating surgical patients with poorly controlled medical conditions with these comorbidities.

A comparison, for older people with diabetes, of health and health care utilisation in two different health systems on the island of Ireland

Background

There are social and economic differences between Northern Ireland (NI) and the Republic of Ireland (ROI). There are also differences in the health care systems in the two jurisdictions. The aims of this study are to compare health (prevalence of diabetes and related complications) and health care utilisation (general practitioner, outpatient or accident and emergency utilisation) among older people with diabetes in the NI and ROI.

Methods

Large scale comparable surveys of people over 50 years of age in Northern Ireland (NICOLA, wave 1) and the Republic of Ireland (TILDA, wave 1) are used to compare people with diabetes (type I and type II) in the two jurisdictions. The combined data set comprises 1536 people with diabetes. A coarsened exact matching approach is used to compare health care utilisation among people with diabetes in NI and ROI with equivalent demographic, lifestyle and illness characteristics (age, gender, education, smoking status and self-related health, number of other chronic diseases and number of diabetic complications).

Results

The overall prevalence of diabetes in the 50 to 84 years old age group is 3.4 percentage points higher in NI (11.1% in NI, 7.7% ROI, p-value < 0.01). The diabetic population in NI appear sicker – with more diabetic complications and more chronic illnesses. Comparing people with diabetes in the two jurisdictions with similar levels of illness we find that there are no statistically significant differences in GP, outpatient or A&E utilisation.

Conclusion

Despite the proximity of NI and ROI there are substantial differences in the prevalence of diabetes and its related complications. Despite differences in the health services in the two jurisdictions the differences in health care utilisation for an equivalent cohort are small.

Factors affecting the likelihood of a hospitalization following a diabetes-related emergency department visit: A regional and urban-rural analysis

BACKGROUND

The objective of this study is to examine place-based and individual-level predictors of diabetes-related hospitalizations that stem from emergency department (ED) visits.

METHODS

We conducted a pooled cross-sectional analysis of the National Inpatient Sample (NIS) for 2009 to 2014 to identify ED-initiated hospitalizations that were driven by the need for diabetes care. The odds of an ED-initiated diabetes-related hospitalization were assessed for the United States as a whole and separately for each census region.

RESULTS

Nationally, residents of noncore areas (odds ratio [OR] 1.10; CI 1.08, 1.12), the South (OR 8.03; CI 6.84, 9.42), Blacks (OR 2.49; CI 2.47, 2.52), Hispanics (OR 2.32; CI 2.29, 2.35), Asians or Pacific Islanders (OR 1.20; CI 1.16, 1.23), Native Americans (OR 2.18; CI 2.10, 2.27), and the uninsured (OR 2.14; CI 2.11, 2.27) were significantly more likely to experience an ED-initiated hospitalization for diabetes care. Census region-stratified models showed that noncore residents of the South (OR 1.17; CI 1.14, 1.20) and Midwest (OR 1.06; CI 1.02, 1.11) had higher odds of a diabetes-related ED-initiated hospitalization.

CONCLUSIONS

As continued efforts are made to reduce place-based disparities in diabetes care and management, targeted focus should be placed on residents of noncore areas in the South and Midwest, racial and ethnic minorities, as well as the uninsured population.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND AND AIMS

Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.

METHODS AND RESULTS

A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.

CONCLUSION

Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Effects of Point-Of-Care Testing in General Practice for Type 2 Diabetes Patients on Ambulatory Visits and Hospitalizations

Point-of-care testing (POCT) of HbA1c means instant test results and more coherent counseling that is expected to improve diabetes management and affect ambulatory visits and hospitalizations. From late 2008, POCT has been implemented and adopted by a segment of the general practices in the capital region of Denmark. The aim of this study is to assess whether the introduction of POCT of HbA1c in general practice (GP) has affected patient outcomes for T2 diabetes patients in terms of hospital activity. We apply difference-in-differences models at the GP clinic level to assess the casual effects of POCT on the following hospital outcomes: (1) admissions for diabetes, (2) admissions for ambulatory care sensitive diabetes conditions (ACSCs), (3) ambulatory visits for diabetes. The use of POCT is remunerated by a fee, and registration of this fee is used to measure the GP’s use of POCT. The control group includes clinics from the same region that did not use POCT. The sensitivity of our results is assessed by an event study approach and a range of robustness tests. The panel data set includes 553 GP clinics and approximately 30,000 diabetes patients from the capital region of Denmark, observed in the years 2004–2012. We find that voluntary adoption of POCT of HbA1c in GP has no effect on hospital admissions and diabetes-related hospital ambulatory visits. Event study analysis and different treatment definitions confirm the robustness of these results. If implementation of POCT of HbA1c improves other parts of diabetes management as indicated in the literature, it seems worthwhile to implement POCT of HbA1c in the capital region of Denmark. However, doubts around the quality of POCT of HbA1c testing and a desire to capture data at central labs may prevent implementation of more value based HbA1c testing.

[Hospitalizations and amputations for diabetes mellitus-trends and small-area variation in Germany]

BACKGROUND

Hospitalizations and lower limb amputations related to diabetes mellitus (DM) are considered to be potentially avoidable. Appropriate outpatient care of diabetes prevents complications. Rates on potentially avoidable hospitalizations for diabetes are core indicators of the German diabetes surveillance program. International comparisons showed high hospitalization rates in Germany for both indicators.

OBJECTIVES

The objective of this analysis is to describe time trends on hospitalizations and inpatient lower limb amputations (major amputations) for DM. Furthermore, we analyze small area variations.

MATERIALS AND METHODS

Based on the German diagnosis related groups (DRGs) dataset we calculated age-standardized rates covering 2005-2015. Calculations rely on the Organisation for Economic Co-operation and Development (OECD) indicator definitions. Time trends are obtained by linear regression modelling. We also stratified into age groups and analyzed 2015 small-area variations using age-adjusted rates.

RESULTS

Crude hospitalization rates were 310 admissions per 100,000 inhabitants in men (amputation rate: 15.6) and 216 admissions per 100,000 inhabitants in women (amputation rate: 7.1) in 2015. Age-adjusted hospitalizations and amputations rates in women decreased over time (10.3 and 1.2 cases per 100,000 inhabitants and year, respectively). In men, the amputation rate decreased significantly (1.5 cases per 100,000 inhabitants and year). We found higher rates for men than for women in almost all age categories. In eastern Germany and parts of Bavaria and North Rhine-Westphalia rates are particularly high.

CONCLUSIONS

A decrease in hospitalization rates may indicate improvements in ambulatory diabetes care over time. Future studies should consider age-specific differences and small-area variations.

Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study

OBJECTIVE

To determine the effect of a large-scale program to strengthen general practice on hospitalisation rates.

METHODS

This observational study compared enrolled patients in the program and a sample of non-participating patients from non-participating GPs in the same geographic area in Germany. Key components of the program are: prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. The outcomes in this study were hospitalisation, rehospitalisation, and avoidable hospital admission up to four years after patient inclusion. Poisson regression models and generalized estimating equations were used to estimate intervention effects.

RESULTS

In the baseline year, 19.1% were hospitalised and 13.6% had a potentially avoidable hospitalisation, 14.5% were rehospitalised within 4 weeks. Across the four observed years, yearly hospitalisations were 9.8 to 14.9% lower in enrolled patients, yearly re-hospitalisations were 5.3 to 11.5% lower, and yearly avoidable hospitalisations were 6.8 to 8.6% lower compared to the control cohort (all differences were statistically significant). The trend in the between-group difference for hospitalisations and re-hospitalisations increased, while it remained stable for avoidable hospitalisations.

CONCLUSION

This study provides strong indications for the positive impact of strong general practice care on population outcomes. Key points A program to strengthen general practice in Germany comprised of prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. Patients who remained in the program during 4 years had increasingly lowered rates of hospitalisation and rehospitalisation compared to a control group of patients. Avoidable hospitalisations were also lower, but no trend of further lowering was found. This might suggest a ceiling effect to impact of strong general practice on hospitalisations.

Identifying patterns of general practitioner service utilisation and their relationship with potentially preventable hospitalisations in people with diabetes: The utility of a cluster analysis approach

AIMS

We aimed to characterise use of general practitioners (GP) simultaneously across multiple attributes in people with diabetes and examine its impact on diabetes related potentially preventable hospitalisations (PPHs).

METHODS

Five-years of panel data from 40,625 adults with diabetes were sourced from Western Australian administrative health records. Cluster analysis (CA) was used to group individuals with similar patterns of GP utilisation characterised by frequency and recency of services. The relationship between GP utilisation cluster and the risk of PPHs was examined using multivariable random-effects negative binomial regression.

RESULTS

CA categorised GP utilisation into three clusters: moderate; high and very high usage, having distinct patient characteristics. After adjusting for potential confounders, the rate of PPHs was significantly lower across all GP usage clusters compared with those with no GP usage; IRR = 0.67 (95%CI: 0.62-0.71) among the moderate, IRR = 0.70 (95%CI 0.66-0.73) high and IRR = 0.76 (95%CI 0.72-0.80) very high GP usage clusters.

CONCLUSIONS

Combination of temporal factors with measures of frequency of use of GP services revealed patterns of primary health care utilisation associated with different underlying patient characteristics. Incorporation of multiple attributes, that go beyond frequency-based approaches may better characterise the complex relationship between use of GP services and diabetes-related hospitalisation.