Kaiser Permanente Study Seeks Insights on What Diabetes Patients Really Want to Ask the Doctor

The short duration of the primary care office visit frustrates doctors and patients alike—and that can mean trouble for persons with type 2 diabetes (T2D), who can consume 15 minutes just with the issues surrounding their disease, let alone anything else that might be bothering them.

So the health insurer Kaiser Permanente, funded by the National Institutes of Health, has embarked on a study to ask patients with uncontrolled T2D ahead of their visit what concerns them—and the answers have been surprising.¹ Findings gathered thus far were presented Saturday at the 76^th Scientific Sessions of the American Diabetes Association, being held in New Orleans, Louisiana.

More than half the time, said lead author Cindy D. Zamudio, BA, of Kaiser Permanente, patients’ top concerns had nothing to do with diabetes—but in some cases that worry could present a barrier to good care.

Even if primary care physicians do not address such issues themselves, she said, it would be wise for managed care organizations to take note. “I would hope the providers can address these issues,” she said.

Zamudio presented results in a guided poster session, “Evaluations of Barriers and Facilitators of Novel Care Delivery,” moderated by O. Kennik Duru, MD, of the David Geffen School of Medicine at UCLA.

According to the abstract, Kaiser sent 2 sets of surveys: a set to 146 primary care providers, with 141 responses; of these, 84% reported insufficient time during visits and 41% said they were often unable to address every agenda item during the visit. Among the barriers to good care:

· 43% said patients were not ready to discuss their top 1 or 2 concerns

· 39% said patients raised concerns at the end of the visit

During her talk, Zamudio focused on survey responses from the 116 patients, who averaged 61 years and were 29% non-white. Slightly more than half (52%) were women. The mean glycated hemoglobin (A1C) was 9.1%.

Patients submitted 183 specific concerns ahead of 116 visits. Less than half, or 55 of 116 (47%) included diabetes as a top concern. Other top concerns included 19% that listed mood or motivation issues (19%), including difficulty coordinating provider visits.

Zamudio said patients listed things like, “my eye is tearing,” “I have black spot on my elbow,” or “my driver’s license was cancelled and I’m very depressed.” These would be indicators for referrals to other specialists or perhaps a social worker, but they require the assistance of a care coordinator, something that Duru noted might be the duty of the broader “medical neighborhood.”

Factors for 30-Day Readmission, Length of Stay. A poster from Penn State University found that comorbidities were the most important factor in determining length of stay for T2D patients, especially dementia (1.43 days) and hemi/paraplegia (2.26 days). After identifying patients with diabetes, those with T2D were more likely to be readmitted, with common reasons being infectious complications (9.4% for patients with T2D vs 7.7% without), heart failure (6.0% vs 3.1%), and chest pain/myocardial infarction (5.5% vs 3.3%).²

Transitions Between Hospital and Primary Care. University of Cincinnati Medical Center (UCMC) researchers conducted a pilot study of an intervention called Sweet Transitions to better coordinate care between hospital and ambulatory settings for patients with poorly controlled diabetes (A1C at least 9%).³ Patients from UCMC and a VA affiliate received in-hospital education prior to discharge, phone follow-up 24 to 72 hours after discharge, and a visit from a nurse practitioner with diabetes care experience. Oral medication or insulin adjustment was provided. Ninety patients, 75% male, average age 58 enrolled. The following were observed:

· In 61 patients with repeat A1C after an average of 114 days, valued decreased from an average of 11.4% to an average of 9.1%.

· A decrease of 3.8% A1C was seen in insulin-naïve patients.

· 30-day readmission rates were lower in the intervention group (6% vs 18% at UCMC; 10% vs 14% at VA).

References

1. Zamudio CD, Vo M, Uratsu CS, Altschuler A, Heisler M, Grant RW. Barriers to effective primary care among patients with poorly controlled type 2 diabetes. Diabetes. 2016; 65(suppl1):1210-P.

2. Hollenbeak CS, Enomoto L, Rosenthal MB, Shrestha D, Gabbay RA. Risk factors associated with 30-day readmission and length of state in type 2 diabetes. Diabetes. 2016;65(suppl1):1215-P.

3. Polanco GG, Corbin AE, Sisson Em, et al. Sweet transitions; coordinating diabetes are between hospital and primary care settings. Diabetes. 2016;65(suppl1):1217-P.