Abstract
Objectives
To examine patient attitudes, experiences, and satisfaction with healthcare associated with office visit utilization among Medicare beneficiaries with type 2 diabetes.
Methods
We analyzed the 2019 Medicare Current Beneficiary Survey Public Use File of beneficiaries aged ≥65 years with type 2 diabetes (n = 1092). The ordinal dependent variable was defined as 0, 1 to 5, and ≥6 office visits. An ordinal partial proportional odds model was conducted to examine associations of beneficiaries’ attitudes, experiences, and satisfaction with healthcare and office visit utilization.
Results
Among the beneficiaries, approximately 17.7%, 22.8%, and 59.5% reported having 0, 1 to 5, and ≥6 office visits, respectively. Being male (OR = 0.67, p = 0.004), Hispanic (OR = 0.53, p = 0.006), divorced/separated (OR = 0.62, p = 0.038) and living in a non-metro area (OR = 0.53, p < 0.001) were associated with a lower likelihood of attending more office visits. Trying to keep sickness to themselves (OR = 0.66, p = 0.002) and dissatisfaction with the ease and convenience of getting to providers from home (OR = 0.45, p = 0.010) were associated with a lower likelihood of having more office visits.
Discussion
The proportion of beneficiaries foregoing office visits is concerning. Attitudes concerning healthcare and transportation challenges can be barriers to office visits. Efforts to ensure timely and appropriate access to care should be prioritized for Medicare beneficiaries with diabetes.
Introduction
Diabetes is a common chronic condition, affecting approximately 26.8% of Americans aged ≥65 years. 1 Individuals with diabetes are at-risk for long-term disease-related complications that require frequent consultation with healthcare providers. 2 According to the US National Ambulatory Medical Care Survey, in 2016, there were an estimated 498.5 office-based physician visits per 100 adults aged ≥65 years. Individuals with diabetes incurred around 24.0% of office visits among adults 65 to 74 years-of-age and 20.8% of visits among those ≥75 years. 3 Regular primary care utilization is associated with better blood glucose regulation, reduced emergency care use, less frequent hospitalization, and lower healthcare costs. 4
The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends Hemoglobin A1c testing approximately every 3 months, blood pressure measurement at every routine clinical visit, regular testing for lipid disorders, and annual screening for kidney disease.5,6 These ADA-recommended assessments require at least 2 to 4 office visits annually.7,8 Variations in the need for and frequency of office visits may be necessitated by differences in the complexity of the condition among individuals with diabetes.
Patient-level characteristics, such as being male, being a racial/ethnic minority, living in a rural area, self-reported health status (e.g. excellent health), and care-seeking preferences (e.g. preference for specialists) have been previously associated with lower participation in office visits with healthcare providers.9–11 Transportation difficulties are known barriers to healthcare access and diabetes care.12,13
Attitudes and concerns about disease and disease self-management can have significant implications on the recommended utilization of healthcare and diabetes self-management practices. 14 Some individuals with diabetes may be concerned with how to properly manage their chronic conditions or the acute complications that may arise. Others may face emotional burdens due to the complexity of the condition, including worry and fear about potential long-term complications.
Information on Medicare beneficiaries’ attitudes and experiences with healthcare, including transportation barriers, on office visit utilization is limited. This gap is especially evident among beneficiaries with diabetes, a chronic condition that often necessitates frequent interactions with providers. Therefore, we aimed to examine associations between attitudes (i.e. worrying about health more than others and trying to keep sickness to themselves), experiences and satisfaction (i.e. satisfaction with the quality of healthcare, satisfaction with the ease/convenience of getting to providers from home) with healthcare and office visit utilization among Medicare beneficiaries aged ≥ 65 years with type 2 diabetes.
Methods
Data
We used the 2019 Medicare Current Beneficiary Survey Public Use File (MCBS PUF) for the current study. The MCBS PUF includes only community-dwelling Medicare beneficiaries. 15 The file contains survey-collected data augmented with administrative data for certain variables (i.e. use of office visits). The dataset contains information on beneficiaries’ socio-demographics, health conditions, and utilization of and satisfaction with healthcare services. 15 This study was considered non-human subjects research, as MCBS PUF data are de-identified and publicly available.
Study population
Our sample population included 1092 Fee-For-Service (FFS) beneficiaries aged ≥ 65 years with reported type 2 diabetes. Beneficiaries were asked, “Has a doctor ever told you that you had any type of diabetes?” Those who indicated “yes” to having diabetes were then asked to specify diabetes type (Supplementary Table 1).
Measures
Dependent variable
The dependent variable was the annual number of physician office visits utilized by a Medicare beneficiary with type 2 diabetes in 2019. This measure was aggregated from administrative FFS claims data. 15 The office visit utilization data was provided on a six-level scale (i.e. 0, 1 to 5, 6 to 10, 11 to 15, 16 to 20, and 21 or more office visits). We recoded these data into a three-level scale (i.e. 0, 1 to 5, and 6 or more office visits) based on the general recommendation of the number of office visits per year for those with diabetes 7 and data distribution.
Key independent variables
Beneficiaries’ attitudes, experiences, and satisfaction with healthcare were measured by four questions. The first two questions allowed a binary response option (yes vs. no) to statements: (1) “You worry about their health more than others at the same age”; and (2) “When you are sick, you try to keep it to yourself”. The last two questions were measured on a 4-point Likert scale ranging from “very dissatisfied” to “very satisfied” to items: (3) “the ease and convenience of getting to a doctor or other health professional from where you live”; and (4) “the overall quality of the health care you received over the past year”. Responses for the last two questions were dichotomized into two categories: 1 = dissatisfied/very dissatisfied or 0 = satisfied/very satisfied to ensure sufficient sample sizes for reliable estimates.
Covariates
The socio-demographic and health-related characteristics were selected based on findings of prior studies on provider visit utilization.10,11 Socio-demographic characteristics included age (65–74, ≥75 years), sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and Other), marital status (married, widowed, divorced/separated, and never married), education level (<high school, high school, and >high school), income (<$25,000, ≥$25,000), residing area (metro, non-metro), and living status (alone, not alone). For the race/ethnicity variable, the category “Other” included beneficiaries who reported they were American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, of 2 or more races, or of another race and not of Hispanic origin. Health-related characteristics included self-assessed health status (excellent/very good, good, and fair/poor), body mass index (BMI: underweight or healthy, overweight, and obese/high-risk obese), physical/functional limitations (no functional limitations, instrumental activities of daily living only, 1 to 2 activities of daily living, and 3 or more activities of daily living), and the number of chronic conditions (0 to 1, 2 to 3, and 4 or more).
Statistical analyses
We first examined differences in office visit utilization by beneficiaries’ socio-demographic and health-related characteristics, as well as respondents’ attitudes, experiences, and satisfaction with healthcare with cross-tabulations and Wald χ2 tests. We then examined the association between the three-level ordinal office visit and key characteristics related to beneficiaries’ attitudes, experiences, and satisfaction with healthcare using the multivariable ordinal partial proportional odds model, adjusting for socio-demographic and health-related characteristics. The partial proportional odds model was chosen (over the proportional odds model) because it allows independent variables to have different coefficients estimated at the different levels of an ordinal dependent variable. For example, the model allows the independent variables to have different coefficients (or odds ratios) estimated for having 1 to 5 or 6 or more office visits versus no office visits, and 6 or more office visits versus 0 or 1 to 5 office visits. We used a stepwise selection method, which is recommended by the SAS technical document, to select variables that exhibit a nonproportional odds ratio and the final model. 16 All analyses were conducted using SAS version 9.4.
There were two variables (i.e. residing area and self-assessed health status) with unequal coefficients/odds ratios based on the stepwise selection method. The interpretations of the results for the unequal coefficients/odds ratios for the three-level ordinal dependent variable of office visits are based on the response function where the base groups are the following: (a) 6 or more office visits versus 0 or 1 to 5 office visits and (b) 1 to 5 or 6 or more office visits versus no office visits (the SAS technical document has provided the explanation of interpretations for the results). 16 For variables without unequal coefficients between different response functions, the same odds ratio applies to the comparison between different levels of office visits (i.e. base groups a and b as described above).
Results
Table 1 presents the socio-demographic and health-related characteristics, as well as key independent variables by the number of office visits. Overall, 17.7% of Medicare beneficiaries with type 2 diabetes reported 0 office visits, 22.8% reported 1 to 5 office visits, and 59.5% reported 6 or more office visits. Those who were older (p = 0.001), women (p < 0.001), married (p = 0.027), lived in a metro area (p = 0.024), had comorbidities (p = 0.002), had physical/functional limitations (p < 0.001), and had fair/poor health status (p < 0.001) reported using more office visits than their counterparts.
Characteristics of Medicare beneficiaries aged ≥ 65 years with reported type 2 diabetes, by office visits.
Unweighted n.
Weighted percentage.
Among beneficiaries who worried about health more than others, approximately 18.9% reported 0 office visits, 16.8% reported 1 to 5, and 64.3% reported 6 or more office visits (vs. not; 17.3%, 24.6%, and 58.0%; p = 0.120). For those who tried to keep sickness to themselves, 18.0% reported 0 office visits, 26.4% reported 1 to 5, and 55.6% reported 6 or more office visits (vs. not; 17.5%, 21.0%, and 61.5%; p = 0.154). For respondents who were dissatisfied with healthcare quality, 17.3% had 0 office visits, 22.8% had 1 to 5, and 59.9% had 6 or more office visits (vs. satisfied; 17.7%, 22.8%, and 59.5%; p = 0.997). For beneficiaries who were dissatisfied with the ease and convenience of getting to providers from home, 35.2% had 0 office visits, 20.8% had 1 to 5, and 44.0% had 6 or more office visits (vs. satisfied; 17.0%, 22.9%, and 60.1%; p = 0.218).
Results from the multivariable ordinal partial proportional odds model are summarized in Table 2. Compared to beneficiaries aged 65 to 74 years, older beneficiaries (aged ≥75 years) were more likely to have more office visits (OR = 1.54; 95% CI = 1.17, 2.03) for response functions that compared (a) 6 or more office visits versus 0 or 1 to 5 office visits and (b) 1 to 5 or 6 or more office visits versus no office visits. Men had a lower likelihood of having more office visits than women (OR = 0.67; 95% CI = 0.51, 0.88) based on both response functions. Compared to non-Hispanic Whites, Hispanics were associated with a lower likelihood of having more office visits (OR = 0.53; 95% CI = 0.33, 0.84) based on both response functions. Divorced/separated beneficiaries had a lower likelihood of utilizing more office visits compared to those who were married (OR = 0.62; 95% CI = 0.39, 0.97). Comparing 6 or more office visits versus 0 or 1 to 5 office visits, living in a non-metro area was associated with a lower likelihood of having more office visits (OR = 0.53; 95% CI = 0.39, 0.70). Beneficiaries with 2 to 3 chronic conditions (OR = 1.58; 95% CI = 1.17, 2.15) and 4 or more chronic conditions (OR = 1.68; 95% CI = 1.14, 2.49) were more likely to have more office visits than those with 0 or 1 chronic conditions. Comparing 6 or more office visits versus 0 or 1 to 5 office visits, beneficiaries with self-reported fair/poor health status (OR = 1.57; 95% CI = 1.07, 2.30) were more likely to utilize more office visits than those in excellent health status for both response functions.
Multivariable ordinal partial proportional odds model to identify characteristics associated with office visits among Medicare beneficiaries aged ≥ 65 years with reported type 2 diabetes.
Odds ratio.
Confidence interval.
Reference group.
Variables with unequal odds in different response functions.
Those who reported trying to keep sickness to themselves (OR = 0.66; 95% CI = 0.51, 0.86) or were dissatisfied with the ease and convenience of getting to providers from home (OR = 0.45; 95% CI = 0.25, 0.83) had a lower likelihood of having more office visits than their counterparts for both response functions. Worry about health more than other people (OR = 1.32; 95% CI = 0.93, 1.88) and dissatisfaction with the quality of healthcare (OR = 0.90, 95% CI = 0.42, 1.93) were not statistically significant in the model.
Discussion
Regular office visits are essential in preventing diabetes-related complications and encouraging self-management in individuals with diabetes. 8 Despite the necessity of regular office visits among individuals with diabetes, the results of our study showed that 17.7% of beneficiaries had no office visits during the year, and 22.8% of beneficiaries with diabetes had 1 to 5 office visits. The lack of participation in office visit utilization may place individuals at risk for late diagnoses and delayed treatments for diabetes-related complications. This finding is consistent with a report by Fenton et al., which illustrated that 35% of older persons (with a mean age of 65 years) with diabetes had 0 to 4 outpatient visits per year, raising concerns and supporting the need to better understand barriers to office visit utilization and importance of the development of interventions to mitigate those barriers. 7
Our findings showed that demographic characteristics, such as age and sex, were associated with office visit utilization. Younger or male beneficiaries had significantly fewer office visits than their counterparts, which corroborates previously published research. 9 Prior study reported less healthcare service utilization, including HbA1c screening and tests for urine, lipids and creatinine among men as compared to women. 17 Although it has been established that men tend to use healthcare services less, more research is needed to identify characteristics that contribute to this observation.
We found that Hispanic beneficiaries with diabetes had significantly fewer office visits than non-Hispanic White beneficiaries. Racial/ethnic disparities in healthcare utilization have been documented in previous studies among those with diabetes. 18 The literature suggests that among adult patients with diabetes in the US, Hispanics are the least likely individuals to receive preventative diabetes care (i.e. A1C tests, foot exam, and eye exam), which may be related to socio-economic status. 9 Therefore, additional resources and culturally-oriented assistance for this minority population is important and needed. Our study also found that beneficiaries who were divorced/separated were less likely to engage in more office visits than those who were married. This may be partly due to the lack of spousal support, a temporary lack of health insurance coverage (losing a spousal insurance coverage), and financial constraints from a divorce and separation.
Our study also illustrated that beneficiaries with diabetes who lived in a non-metro area had significantly fewer office visits than their counterparts. Individuals who live in rural communities often encounter multiple barriers to preventive care, including travel-related difficulties and financial-related problems. 19 Efforts to reduce these barriers are important to improve diabetes self-management and care for this at-risk population. Participation in diabetes self-management education (DSME) has been associated with greater involvement in preventative care, including office visits and other preventive practices. 20 Unfortunately, DSME remains an underutilized intervention in diabetes care, especially among rural-residing individuals. 20 Strategies to improve diabetes management in rural areas, including telemedicine programs, telephone help lines, and support delivered via community health workers have shown promise in improving diabetes care and health outcomes for those living with diabetes in rural communities. 19
Our study illustrated that chronic illness burden was positively associated with greater office visit utilization in Medicare beneficiaries with type 2 diabetes. This is likely because diabetes-associated chronic conditions, such as cardiovascular disease, kidney disease, and neuropathy, frequently require specialty consultation, in addition to routine diabetes care. Excessive disease burden and associated healthcare utilization that arise from diabetes complications can be avoidable. However, strategies to support preventative diabetes care at the time of diagnosis, promotion of consistent medication taking behavior, and screening for those at-risk of inconsistent use of healthcare are needed.8,21,22
Our results highlighted that beneficiaries with diabetes who tried to keep sickness to themselves experienced lower office visit utilization. This specific attitude concerning their health may be present because some individuals perceive their condition to be less serious, leading them to postpone testing to diagnose diabetes-related complications and medical treatments. 23 In a study examining knowledge of the warning signs of foot ulcer deterioration among persons with diabetes, 75.8% of participants felt they should seek medical treatment of diabetic foot ulcers only when a wound experienced deterioration. 24 Therefore, office visits allow healthcare professionals to evaluate individuals with diabetes to avoid undiagnosed or delayed treatment of complications.
It is worth noting that some individuals may feel that their condition is burdensome to caregivers or family members, and therefore, they may withhold sharing their health conditions or concerns with others. Coping in this manner to avoid stigmatization may exacerbate negative behaviors. Results from an Australian study on perceptions and experience of diabetes-related stigma found that although, patients reported that they have supportive families, friends, and coworkers, individuals with diabetes still experience perceived unhelpful or even annoying behaviors regarding diet and weight management. 25 Hence, it is imperative that family-centered, psychosocial interventions be developed to improve diabetes self-care engagement/management, and health outcomes. Regular office visits are important opportunities for providers to screen or counsel individuals with diabetes who might be at risk of these behaviors.
Our study also found that beneficiaries who were dissatisfied with the ease and convenience of getting to providers from home had fewer office visits. Access to reliable means of transportation is essential to obtain needed care, especially for older adults. Previous research has shown that patients with diabetes may encounter transportation-related barriers, 12 such as lack of access to affordable, reliable transportation. 13 Therefore, improving the availability of transportation services for older adults with diabetes may help them to better manage the disease with up-to-date health assessment and needed care. Alternative healthcare delivery options including telehealth and home visitation may be particularly useful in improving healthcare access to this at-risk population of people with diabetes.
There are several possible limitations to this study. Our study focused on the community-dwelling Medicare population with type 2 diabetes. Therefore, our results may not be generalizable to individuals who live in long-term care facilities or those with type 1 diabetes. Although we included comorbidities in the model, other diabetes-related complications, such as neuropathy, were not available in the dataset, which may impact our findings. As many variables were self-reported, they might suffer from self-reporting biases and interpretations. The office visit utilization level was aggregated from administrative FFS claims data and was defined as a categorical variable (instead of a count variable) in MCBS PUF by CMS, which limited the specific statistical analysis that could be performed. Also, the specific reasons for office visits were not available, the information might provide additional insight into the preventive care seeking behaviors among beneficiaries with diabetes. Qualitative studies that can better understand the motivations and barriers to engaging in office visits are warranted.
In conclusion, the proportion of beneficiaries with no office visits, even in the presence of insurance coverage, raises concerns. Attitudes toward healthcare and transportation challenges are important barriers to office visit utilization among Medicare beneficiaries with type 2 diabetes. Efforts to ensure that older adults in need of adequate diabetes care receive appropriate screening, counseling, and treatment should be prioritized. Regular office visits are central channels for healthcare providers to understand the needs, attitudes, and beliefs of older adults with diabetes. Consistent contact with healthcare providers is essential to identification and timely intervention for evolving problems in people with diabetes.
Contributorship
Q.H. contributed to the design and statistical analysis of the study, interpreted the data, wrote, and revised the manuscript. B.P.N. contributed to the design of the study, provided guidance on the content of the manuscript, interpreted the data, and made a critical revision of the manuscript. G.T.H., C.P., S.H., and J.B.L. interpreted the data and revised the manuscript. Q.H. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Supplemental Material
sj-docx-1-chi-10.1177_17423953231158139 - Supplemental material for Patient attitudes, experiences, and satisfaction with healthcare and office visit utilization among Medicare beneficiaries with type 2 diabetes
Supplemental material, sj-docx-1-chi-10.1177_17423953231158139 for Patient attitudes, experiences, and satisfaction with healthcare and office visit utilization among Medicare beneficiaries with type 2 diabetes by Qing He, Georgianne Tiu Hawkins, Chanhyun Park, Sola Han and Jacqueline B. LaManna, Boon Peng Ng in Chronic Illness
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
IRB determined that the proposed activity is not research involving human subjects as defined by DHHS and FDA regulations.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Guarantor
Q.H.
Informed consent
Informed consent was not applicable to this study because it is based on publicly available data from the CMS.
Supplemental material
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References
Supplementary Material
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