Unmet Primary Care Needs in Diabetic Patients with Multimorbidity in a Medically Underserved Area

Abstract

Background:Diabetic patients with multimorbidity in medically underserved minority communities are less engaged in primary care and experience high emergency department (ED) utilization. This study assesses unmet primary care needs among diabetic patients in a medically underserved area (MUA).Community Context:A suburb of Memphis—Whitehaven, Tennessee (Shelby County, ZIP codes 38109 and 38116)—majority African American (96.6%) with 30.5% below the poverty level.Methods:Community case study using multiple data sources including diabetes registry, individual interviews, focus groups, and a survey of 30 ED patients with diabetes and multimorbidity.Results:Diabetes registry data indicated that 95.5% of 5723 diabetic patients had multimorbidity. Over 91.5% were uncontrolled at some point in 2014 to 2015. Only 83% of patients with diabetes and multimorbidity reported having a primary care provider (PCP) and those without a PCP were more likely to report delays in needed care. Patients expressed strong interest in health coaching (88%) and receiving text messages from the doctor’s office (73%). Individual patient interviews (n = 9) and focus groups (n = 11) revealed common primary care and self-care experiences and needs including diabetes education, improved patient–provider communication, health-care access and coverage, and strengthened primary care and community.Conclusion:This study demonstrates that almost 1 in 5 ED complex diabetic patients in an MUA do not have a PCP, and that difficulty accessing primary care often results in patients forgoing needed care. Qualitative findings support these conclusions. These results suggest that primary care capacity and infrastructure to support diabetes self-care need strengthening in MUAs.

Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults

“…Risk factors that assault multiple body systems are prevalent among racial and ethnic minority populations in the U.S.—for example, obesity, chronically elevated stress levels, or elevated systemic inflammatory markers—and may, in turn, lead to earlier multimorbidity development [36–38]. In addition, poor access to good quality health care and low socioeconomic status may exacerbate and accelerate additional chronic disease development [39]. For example, Hispanic adults have greater prevalence of obesity and greater risk of developing diabetes in midlife [34].…”

Can primary care access reduce health care utilization for patients with obesity‐associated chronic conditions in medically underserved areas?

“…Fourth, access to primary care was based on self‐report by the patient at ED or hospital registration, which may be biased due to self‐reporting and could not be confirmed given the retrospective nature of the study. However, our previous study demonstrates that self‐report at registration in the participating health system accurately reflects access to primary care 36 . Fifth, prevalence of OCC and health care utilization were measured using hospital and ED records within one hospital system, this may have led to an underestimation of prevalence of comorbid conditions as well as utilization.…”

“…However, our previous study demonstrates that self-report at registration in the participating health system accurately reflects access to primary care. 36 Fifth, prevalence of OCC and health care utilization were measured using hospital and ED records within one hospital system, this may have led to an underestimation of prevalence of comorbid conditions as well as utilization. Though the prevalence of OCC captured might be lower using only hospital records, 46 multiple previous studies have reliably used hospital records to identify chronic conditions or multiple chronic conditions.…”

“…Broadly, patient response can be categorized as reporting: (1) “name of primary care physician (PCP)/nurse practitioner (NP),” (2) “name of clinic as source of regular care, if name of PCP/NP not known,” or (3) “none.” For this study, we categorized self‐reported access to primary care as “no” if the patient response was none and “yes” if they reported either of (1) or (2) as above. Our previous study demonstrates that self‐report at registration in the participating health system accurately reflects access to primary care 36,37 . Patient residence ZIP codes were linked to the CMS database of HPSA and low‐income zip codes to identify patients residing in HPSA and low‐income areas, respectively 38 .…”

“…Our previous study demonstrates that self-report at registration in the participating health system accurately reflects access to primary care. 36,37 Patient residence ZIP codes were linked to the CMS database of HPSA and low-income zip codes to identify patients residing in HPSA and low-income areas, respectively. 38…”