Transcript No Slide Title

Content of Primary Care Visits by Adults with Type 2 Diabetes
A STARNet Study
Michael L. Parchman, MD, MPH; Jacqueline A. Pugh, MD; Raquel Romero, MD
Selected Results
Background and Methods
Results
Performance of Indicated
Diabetes Services
4%
25%
New patient
80
70
Established with
complaint
Established no
complaint
70
68
59
60
% of Visits
Problem: Although over 80% of all physician visits by adults with type 2 diabetes
are to primary care physicians, little is known about the content of those visits,
what diabetes-specific services are provided, and the number of issues
addressed.
Participants: Direct observation of visits by 8-10 adult patients with type 2
diabetes in 18 different primary care offices.
Data Collection: A trained observer was present in the exam room for each visit
and recorded number of topics discussed, length of the visit, number of
prescriptions refilled, number of diabetes-specific services accomplished and
number of physical exam items done.
Outcome Measure: Delivery of an indicated diabetes-related service was
counted as ‘yes’ if any of the following five services had not been done in the past
12 months and were performed during the observed visit: a foot exam, a referral
for an eye exam, a HbA1c, lipid profile or micro-albumin test; or if diet was
discussed during the visit.
54
50
45
40
30
24
20
10
71%
0
Diet Discuss
A1c order
Figure 1
Foot Exam
Eye Referral
Length of Visit and Delivery of
All Indicated Diabetes Services
19.5
19
18.5
18
17.5
Minutes 17
16.5
16
15.5
15
14.5
30.00
20.00
10.00
R Sq Linear = 0.381
No
Yes
All Services Deliverd?
0.00
• A total of 175 visits were directly observed in 18 different clinics.
Microalbumin
Figure 2
Length of Visit and Number of
Topics Discussed
Number
of Topics
Discussed
Lipid Order
0.00
10.00
20.00
30.00
t-test = 2.9, p < .05
40.00
Minutes
• The mean number of additional chronic illnesses per patient was 4.6 (SD 2.3)
• The mean number of chronic medications per patient was 6.4 (SD 3.1)
Figure 3
Conclusions
Figure 4
• A mean of 2.2 (S.D. 1.8) medication prescriptions were provided during the visit.
• In 25% of all visits there was a change in medications.
• The mean length of each visit was 17.5 (S.D. 9.1) minutes.
• An average of 15.5 (S.D. 7.7) topics were discussed per visit, for an average of 1.1
minutes per topic.
• 71% of all patients presented with an acute complaint. (Figure 1)
• Out of 10 possible physical exam items, a mean of 4.3(S.D. 2.7) were performed
per visit.
• The percent delivery of each indicated diabetes service is shown in Figure 2.
• As the number of topics discussed increased, so did the mean length of visit(r =
0.56, p<.001) (Figure 3)).
• Visits with delivery of all indicated diabetes services were significantly longer than
visits where less than all services were delivered. (t-test = 2.90, p < .05) (Figure 4)
 Visits by adult patients with type 2 diabetes to primary care physicians are complex
and demanding.
 Prior studies in primary care settings have found that multiple competing demands
during the physician-patient encounter force clinicians to prioritize those demands and
only deal with the most pressing or symptomatic problem.
 A similar phenomenon may limit the delivery of indicated diabetes related services in
this setting.
 Interventions designed to improve the quality of diabetes care in primary care
practices should take into account the complex competing demands within the primary
care office encounter.
Acknowledgement: Funding for this study was provided by AHRQ, Grant # K08
HS013008-02; HRSA Grant # 5D12HP00008-02; the Department of Veteran Affairs,
HSR&D; and the South Texas Health Research Center. Special thanks to the
physicians and staff of the South Texas Ambulatory Research Network. (STARNet)
Contact email: [email protected]