Brief Report
Receipt of Diabetes Preventive Services Differs by Insurance Status at Visit

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Background

Lack of insurance is associated with suboptimal receipt of diabetes preventive care. One known reason for this is an access barrier to obtaining healthcare visits; however, little is known about whether insurance status is associated with differential rates of receipt of diabetes care during visits.

Purpose

To examine the association between health insurance and receipt of diabetes preventive care during an office visit.

Methods

This retrospective cohort study used electronic health record and Medicaid data from 38 Oregon community health centers. Logistic regression was used to test the association between insurance and receipt of four diabetes services during an office visit among patients who were continuously uninsured (n=1,117); continuously insured (n=1,466); and discontinuously insured (n=336) in 2006–2007. Generalized estimating equations were used to account for within-patient correlation. Data were analyzed in 2013.

Results

Overall, continuously uninsured patients had lower odds of receiving services at visits when due, compared to those who were continuously insured (AOR=0.73, 95% CI=0.66, 0.80). Among the discontinuously insured, being uninsured at a visit was associated with lower odds of receipt of services due at that visit (AOR=0.77, 95% CI=0.64, 0.92) than being insured at a visit.

Conclusions

Lack of insurance is associated with a lower probability of receiving recommended services that are due during a clinic visit. Thus, the association between being uninsured and receiving fewer preventive services may not be completely mediated by access to clinic visits.

Introduction

Preventive diabetes care decreases the risk of complications.1, 2, 3, 4 Yet, despite the effectiveness of preventive care, many patients delay or forgo recommended services.5, 6 One factor contributing to this phenomenon is lack of health insurance; uninsured people are less likely to receive healthcare services than insured,7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 even at community health centers (CHCs) providing services at low or no cost to many uninsured patients.10, 12, 15

Lack of insurance is associated with fewer office visits.18, 19, 20, 21, 22, 23, 24 It is unclear, however, whether access to primary care visits is sufficient to ensure that uninsured patients receive needed services, or whether insurance status is related to differential receipt of care even when patients have visits. It is hypothesized that there is a significant association between insurance status and receipt of recommended diabetes services at visits when services are due.

Section snippets

Methods

This study used electronic health record (EHR) data from 38 Oregon clinics in the OCHIN network (originally called the Oregon Community Health Information Network, but shortened to OCHIN when membership expanded beyond Oregon) with fully operational EHRs by 2005. Each patient has a single medical record shared across all OCHIN network clinics.13 Adults (aged ≥18 years) with diabetes were identified who had two or more primary care visits associated with an ICD-9 code for diabetes (type 1 or 2)

Results

Demographic characteristics of the study population and visit characteristics by insurance status are shown in Table 1.

When considered in aggregate, continuously uninsured patients had lower odds of receiving services at visits when due, compared to the continuously insured (AOR=0.73, 95% CI=0.66, 0.80) (Figure 1A). When examining individual services, odds were significantly lower for all four services (HbA1c: AOR=0.86, 95% CI=0.77, 0.97; LDL: AOR=0.67, 95% CI=0.59, 0.76; microalbumin:

Discussion

Lack of health insurance is associated with poorer diabetes control.23 Previous studies10, 15, 23, 28 suggest that this could be due to uninsured patients utilizing fewer healthcare services than insured patients. This study adds new information to help explain this disparity: Even when uninsured patients use healthcare services, they are still less likely to receive recommended diabetes preventive care at a visit compared to insured patients.

There are plausible reasons for uninsured patients

Acknowledgments

We are grateful to OCHIN, Inc., and the participating clinics for making this research possible. We would like to acknowledge Carrie Tillotson, MPH, for her assistance with the production of Figure 1.

This study was supported by grant No. R01HL107647 from the National Heart, Lung, and Blood Institute and grant No. K08HS021522 from the Agency for Healthcare Research and Quality.

The study sponsor had no role in study design; collection, analysis, or interpretation of data; writing the report; or

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