Variation in the 11-year trajectories of medical care seeking behaviors in diabetes patients under a single payer system: persisting gaps to be filled.

BACKGROUND: Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. METHODS: We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. RESULTS: Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. CONCLUSIONS: This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.

Severe diabetes complications among patients with diabetes with regular follow-up: Does care setting matter?

OBJECTIVE: To investigate diabetes outcomes by long-term trajectories of patients' care settings among diabetes patients with regular follow-up. RESEARCH DESIGN AND METHODS: This longitudinal population-based cohort study used data from the National Health Insurance Research Database in Taiwan. The trajectories of diabetes care-seeking behaviours among newly diagnosed diabetes patients with regular follow-up were identified using a group-based trajectory model from 2000 to 2004. Severe diabetes complications were assessed for the period 2005-2010. Cox-proportional hazard method with a cumulative incidence function was applied. RESULTS: Among the diabetes patients with regular follow-up during the first 5 years since diagnosis, 44.5% and 40.6% were persistently cared for in generalized care settings and specialized settings, respectively. Only 14.9% of them had shifted between different levels of care setting during the first 5 years. No significant difference in adverse outcomes was observed between patients who were persistently treated in generalized and specialized care settings. Significantly worse outcomes were observed among patients who shifted from generalized care settings to specialized settings (adjusted hazard ratio [aHR]=3.2, 95% confidence interval [CI]: 1.5, 6.8). In contrast, among the elderly, regular users of generalized care providers had a higher hazard of adverse outcomes than those of specialized care providers (aHR = 3.3, 95% CI: 1.0, 10.7). CONCLUSIONS: Diabetes patients who were persistently treated in generalized care settings had health outcomes comparable to those who were persistently treated in specialized care settings. However, for elderly and less stable patients, regular diabetes care in specialized care settings was preferable.