Problem: Although over 80% of all physician visits by adults with type 2 diabetes are to primary car

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Content of Primary Care Visits by Adults with
Type 2 Diabetes A STARNet Study Michael L.
Parchman, MD, MPH Jacqueline A. Pugh, MD Raquel
Romero, MD
Selected Results
Background and Methods
Problem Although over 80 of all physician
visits by adults with type 2 diabetes are to
primary care physicians, little is known about
the content of those visits, what
diabetes-specific services are provided, and the
number of issues addressed. Participants Direct
observation of visits by 8-10 adult patients with
type 2 diabetes in 18 different primary care
offices. Data Collection A trained observer was
present in the exam room for each visit and
recorded number of topics discussed, length of
the visit, number of prescriptions refilled,
number of diabetes-specific services accomplished
and number of physical exam items done. Outcome
Measure Delivery of an indicated
diabetes-related service was counted as yes if
any of the following five services had not been
done in the past 12 months and were performed
during the observed visit a foot exam, a
referral for an eye exam, a HbA1c, lipid profile
or micro-albumin test or if diet was discussed
during the visit.
Figure 1
Figure 2
Results

• A total of 175 visits were directly observed in
  18 different clinics.
• The mean number of additional chronic illnesses
  per patient was 4.6 (SD 2.3)
• The mean number of chronic medications per
  patient was 6.4 (SD 3.1)
• A mean of 2.2 (S.D. 1.8) medication
  prescriptions were provided during the visit.
• In 25 of all visits there was a change in
  medications.
• The mean length of each visit was 17.5 (S.D.
  9.1) minutes.
• An average of 15.5 (S.D. 7.7) topics were
  discussed per visit, for an average of 1.1
  minutes per topic.
• 71 of all patients presented with an acute
  complaint. (Figure 1)
• Out of 10 possible physical exam items, a mean
  of 4.3(S.D. 2.7) were performed per visit.
• The percent delivery of each indicated diabetes
  service is shown in Figure 2.
• As the number of topics discussed increased, so
  did the mean length of visit(r 0.56, plt.001)
  (Figure 3)).
• Visits with delivery of all indicated diabetes
  services were significantly longer than visits
  where less than all services were delivered.
  (t-test 2.90, p lt .05) (Figure 4)

Figure 4
Figure 3
Conclusions

• Visits by adult patients with type 2 diabetes to
  primary care physicians are complex and
  demanding.
• Prior studies in primary care settings have
  found that multiple competing demands during the
  physician-patient encounter force clinicians to
  prioritize those demands and only deal with the
  most pressing or symptomatic problem.
• A similar phenomenon may limit the delivery of
  indicated diabetes related services in this
  setting.
• Interventions designed to improve the quality of
  diabetes care in primary care practices should
  take into account the complex competing demands
  within the primary care office encounter.

Acknowledgement Funding for this study was
provided by AHRQ, Grant K08 HS013008-02 HRSA
Grant 5D12HP00008-02 the Department of Veteran
Affairs, HSRD and the South Texas Health
Research Center. Special thanks to the physicians
and staff of the South Texas Ambulatory Research
Network. (STARNet) Contact email
parchman_at_uthscsa.edu