Diabetes Preventive-Care Practices in Managed-Care Organizations -- Rhode Island, 1995-1996

Diabetes mellitus affects 8% of the U.S. adult population and can lead to debilitating complications, including blindness, renal failure, cardiovascular disease, mobility impairment, and lower extremity amputation (1). Preventive care such as glycemic control and regular foot and eye examinations are recommended because of their efficacy in reducing diabetes-related complications (2-6). In the United States, managed care is an important provider of medical services for persons with diabetes (7-9). Persons with diabetes receiving care from a major health-maintenance organization (HMO) or a major preferred provider organization (PPO) in Rhode Island were surveyed in 1995 and 1996 to assess the level of care for three recommended preventive-care practices (2) for diabetes: an annual dilated eye examination, semi-annual foot examination, and annual glycosylated hemoglobin (GHb) assessment. This report summarizes the findings from this survey, which indicated that 87% of persons with diabetes received eye examinations and approximately 55% received semi-annual foot examinations and annual GHb assessments.

A total of 455 persons with diabetes were sampled randomly from lists of persons with diabetes assembled using administrative data from two large Rhode Island managed-care organizations (MCOs)*; 375 persons aged 20-85 years (mean: 57 years) were interviewed (82% response rate), and complete data were present for 351 persons (77%). Respondents were asked how many times in the 12 months before the survey their health-care provider examined their feet, and how many times they received GHb assessments and dilated eye examinations (interviewers defined the term "dilated" for each respondent). Proportions and confidence intervals for each preventive-care practice were computed and stratified by sex, age, type of health-care organization, insulin use, and years since diagnosis of diabetes. Multiple logistic regression was used to evaluate associations among sex, age group, insulin use, diabetes duration, and health service, with preventive-care practices controlling for all other variables. Analyses were conducted using Statistical Package for the Social Sciences.

Of the 351 respondents, 198 (56%) were men, 141 (40%) were insulin users, 95 (27%) were aged greater than or equal to 65 years (Table 1), 305 (87%) reported receiving annual dilated eye examinations, 204 (58%) reported semi-annual foot examinations, and 190 (54%) received an annual GHb assessment. Among persons aged greater than or equal to 65 years, 86 (91%) persons reported eye examinations and 57 (60%) reported foot examinations. Among persons aged 20-44 years, 35 (73%) reported eye examinations and 26 (54%) reported foot examinations. Among persons using insulin, 130 (92%) and 102 (72%) received eye examinations and foot examinations, respectively; 174 (83%) and 103 (49%) persons not using insulin reported eye examinations and foot examinations, respectively. Older persons were less likely than younger persons to have reported receiving GHb assessments (48% for persons aged greater than or equal to 65 years compared with 71% for persons aged 20-44 years). These trends were maintained after multivariate adjustment for sex, age group, insulin use, diabetes duration, and health service.

Reported by: JP Fulton, PhD; DL Goldman, MPH; DK Perry, MPA; Diabetes Control Program, Rhode Island Dept of Health. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

For persons with diabetes, eye and foot examinations and GHb assessments are important because these measures are efficacious and cost effective in identifying opportunities to prevent vision loss, renal failure, and lower extremity disease (3-6). However, for persons with diabetes, the levels of preventive-care practices vary widely across settings, with 23%-83% receiving eye examinations, 25%-65% receiving foot examinations, and 38%-81% receiving GHb assessments (9).

The finding that 87% of patients received eye examinations (5) is higher than findings reported previously (10) and may reflect efforts to enhance retinopathy screening. During the late 1970s, the Rhode Island Diabetes Control Program supported multiple initiatives to promote regular dilated eye examinations for persons with diabetes. These efforts included statewide and locally targeted media campaigns to educate both patients and providers. With various health-care delivery organizations, the Rhode Island program also funded no-cost eye examinations for low income persons, and developed and implemented physician reminders to encourage them to refer patients for routine eye care.

Although the rates of eye examinations are high, 42% of persons with diabetes did not receive semi-annual foot examinations and 46% did not receive GHb assessments. The use of these services in the MCO setting in this survey is similar to previous estimates in fee-for-service and other MCO settings (9), and indicate a need for MCOs to increase efforts to educate patients and providers and to remove barriers to preventive care.

Findings of higher retinopathy screening but lower GHb assessment rates for persons aged greater than or equal to 65 years may indicate that providers consider vision loss a greater concern for the elderly and glycemic control a greater concern for younger persons with diabetes. The findings that insulin users were more likely to receive preventive-care practices may be because insulin use is a marker of disease severity, triggering providers to provide more comprehensive preventive care. Although risk for complications is higher among persons who require insulin, the long-term risk for complications also is considerable and may warrant provider and patient awareness about the value of preventive-care practices for persons with diabetes who do not require insulin therapy.

The three recommended preventive-care practices on which the study focused had existed for 7 years before the survey (1); however, diabetes treatment in Rhode Island conformed only moderately with those recommendations. An approach to improving the level of care may be to work directly with insurers, health-care systems, providers, and patients to promote the use of these services.

The findings in this report are subject to at least three limitations. First, preventive-care practices were measured by self-reports, which can result in recall bias for foot and dilated eye examinations and for GHb assessments. Second, persons were sampled from two major MCOs proportional to the MCO size, therefore, these findings may not represent all segments of the population or all MCO practices in Rhode Island. Third, the survey was conducted in 1996, and MCO practices may have changed since then.

CDC and the Rhode Island Diabetes Control Program are collaborating with community-based organizations and health-care providers in the state. The Rhode Island Diabetes Control Program is piloting an electronic diabetes-care surveillance system to assist health-care providers and insurers to monitor conformity to standards of diabetes care. These efforts should improve diabetes care and help to reduce the burden of diabetes complications.

References

1. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. Diabetes Care 1998;21:518-24.
2. American Diabetes Association. Clinical practice recommendations 1999. Diabetes Care 1999; 22(suppl 1):S1-S114.
3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
4. Litzelman D, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: a randomized, controlled trial. Ann Intern Med 1993;119:36-41.
5. Javitt JC, Aiello LP, Chiang YP, Ferris FL, Canner JK, Greenfield S. Preventative eye care in people with diabetes is cost-saving to the federal government. Diabetes Care 1994;17:909-17.
6. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet 1998;352:837-52.
7. Geffner DL. Diabetes care in health maintenance organizations. Diabetes Care 1992;15 (suppl 1):44-50.
8. Quickel KE. Diabetes in a managed care system. Ann Intern Med 1996;124:160-3.
9. CDC Diabetes in Managed Care Work Group. Exploring and expanding the research agenda for diabetes in managed care: a report of a CDC-managed care workshop. Diabetes Care 1999;22:1734-8.
10. CDC. Continuing diabetes care--Rhode Island, 1991. MMWR 1994;43:798-800.

* Persons with diabetes were identified from sources such as hospital discharge diagnoses, outpatient diagnoses, laboratory test records, pharmacy records, and self-identification.

TABLE 1. Percentage of person with diabetes who received one or more dilated eye examinations per year, two or more foot examinations per year, or one or more glycosylated hemoglobin (GHb) assessments per year, by sex, age group, insulin use, and type of health service -- Rhode Island, 1995-1996

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