Journal of General Internal Medicine

, Volume 24, Issue 3, pp 327–333

Effect of Advanced Access Scheduling on Processes and Intermediate Outcomes of Diabetes Care and Utilization

  • Usha Subramanian
  • Ronald T. Ackermann
  • Edward J. Brizendine
  • Chandan Saha
  • Marc B. Rosenman
  • Deanna R. Willis
  • David G. Marrero
Original Article

ABSTRACT

BACKGROUND

The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied.

OBJECTIVE

To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits).

METHODS

We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes.

RESULTS

Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to non-African Americans [OR 0.27 (CI: 0.21-0.36)]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 – 7.5). There were no differences by clinic type in any of the three health-care utilization outcomes.

CONCLUSION

OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial.

KEY WORDS

diabetes open access process of care outcomes utilization 

References

  1. 1.
    Goiten M. Waiting patiently. N Engl J Med. 1990;323:604–8.CrossRefGoogle Scholar
  2. 2.
    Cunningham P, Clancy C, Cohen J, et al. The use of hospital emergency departments for non-urgent health problems: a national perspective. Med Care Res Rev. 1995;52:453–74.PubMedCrossRefGoogle Scholar
  3. 3.
    Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.Google Scholar
  4. 4.
    Bundy DG, Randolph GD, Murray M, Anderson J, Margolis PA. Open access in primary care: results of a North Carolina pilot project. Pediatrics. 2005;116(1):82–7. Jul.PubMedCrossRefGoogle Scholar
  5. 5.
    Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035–40.PubMedCrossRefGoogle Scholar
  6. 6.
    Murray M, Bodenheimer T, Rittenhouse D, Grumbach K. Improving timely access to primary care: case studies of the advanced access model. JAMA. 2003;289(8):1042–6. Feb 26.PubMedCrossRefGoogle Scholar
  7. 7.
    Parente DH, Pinto MB, Barber JC. A pre-post comparison of service operational efficiency and patient satisfaction under open access scheduling. Health Care Manage Rev. 2005;30(3):220–8. Jul-Sep.PubMedGoogle Scholar
  8. 8.
    Murray M, Tantau C. Same-day appointments. Exploding the access paradigm. FPM. 2000;7:45–50.Google Scholar
  9. 9.
    Harkinson MT, Blumenfrucht FD. Sustained improvement for specialty clinic access. Jt Comm J Qual Patient Saf. 2006;32(3):142–51.Google Scholar
  10. 10.
    Schall MW, Duffy T, Krishnamurthy A, Levesque O, Mehta P, Murray M, et al. Improving patient access to the Veterans Health Administration’s primary and specialty care. Jt Comm J Qual Patient Saf. 2004;30(8):415–23.Google Scholar
  11. 11.
    Siegel D. Advanced-access scheduling in primary care. JAMA. 2003;290(3):333. Jul 16; author reply 333–334.PubMedCrossRefGoogle Scholar
  12. 12.
    Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of care and other determinants of patient satisfaction with primary care. J Gen Intern Med. 2005;20:226–33.PubMedCrossRefGoogle Scholar
  13. 13.
    Manian FA. Whither continuity of care. N Engl J Med. 1999;340:1362–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Parchman ML, Pugh JA, Noel PH, Larme AC. Continuity of care, self-management behaviors, and glucose control among patients with type 2 diabetes. Med Care. 2002;40:137–44.PubMedCrossRefGoogle Scholar
  15. 15.
    Hebert PL, Geiss LS, Tierney EF, Engelgau MM, Yawn BP, McBean AM. Identifying persons with diabetes using Medicare claims data. Am J Med Qual. 1999;14(6):270–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Kerr EA, Gerzoff RB, Krein SL, et al. A comparison of diabetes care quality in the Veterans Affairs Healthcare System and commercial managed care: results from the TRIAD Study. Ann of Intern Med. 2004;141:272–81.Google Scholar
  17. 17.
    Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. Diabetes Care. 1998;21(4):518–24.PubMedCrossRefGoogle Scholar
  18. 18.
    Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–86.CrossRefGoogle Scholar
  19. 19.
    Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136–41.PubMedCrossRefGoogle Scholar
  20. 20.
    Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in quality of care and racial disparities in Medicare Managed care. N Engl J Med. 2005;353:692–700.PubMedCrossRefGoogle Scholar
  21. 21.
    Ilag LL, Martin CL, Tabaei BP, Isaman DJ, Burke R, Greene DA, Herman WH. Improving diabetes processes of care in managed care. Diabetes Care. 2003;26(10):2722–7.PubMedCrossRefGoogle Scholar
  22. 22.
    HEDIS. Health Plan Employer Data and Information Set. Washington, DC: National Committee for Quality Assurance; 1999.Google Scholar
  23. 23.
    McDonald CJ, Blevins L, Tierney WM, et al. The Regenstrief medical records. MD Comput. 1988;5:34–47.PubMedGoogle Scholar
  24. 24.
    McDonald CJ, Overhage JM, Tierney WM, et al. The Regenstrief Medical Record System: a quarter century experience. Int J Med Informatics. 1999;54:225–53.CrossRefGoogle Scholar
  25. 25.
    Willis DR, Kelton GM, Saywell RM Jr, Kiovsky RD. An incentive compensation system that rewards individual and corporate productivity. Family Medicine. 2004;36(4):270–8.PubMedGoogle Scholar
  26. 26.
    Fleming BB, Greenfield S, Engelgau MM, Pogach LM, Clauser SB, Parrott MA. The Diabetes Quality Improvement Project: moving science into health policy to gain an edge on the diabetes epidemic. Diabetes Care. 2001;24:1815–20.PubMedCrossRefGoogle Scholar
  27. 27.
    Greenfield S, Kaplan SH. Creating a culture of quality: the remarkable transformation of the department of Veterans Affairs Health Care System (Editorial). Ann Intern Med. 2004;141:316–8.PubMedGoogle Scholar
  28. 28.
    McClain MR, Wennberg DE, Sherwin RW, Steinmann WC, Rice JC. Trends in the diabetes quality improvement project measures in Maine from 1994 to 1999. Diabetes Care. 2003;26:597–601.PubMedCrossRefGoogle Scholar
  29. 29.
    National Committee for Quality Assurance, American Diabetes Association: Diabetes Quality Improvement Project Initial Measure Set (Final Version). Available at http://www.ncqa.org/dprp/dqip2.htm.
  30. 30.
    Mangione CM, Gerzoff RB, Williamson DF, et al. Association of diabetes disease management programs’ intensity with process and outcomes measures of quality of care: The Translating Research into Action for Diabetes (TRIAD) Study. Ann Intern Med. 2006;145:107–16.PubMedGoogle Scholar
  31. 31.
    Ackermann RT, Thompson TJ, Selby JV, et al. Is the number of documented diabetes process-of-care indicators associated with cardio-metabolic risk factor levels, patient satisfaction, or self-rated quality of diabetes care. Diabetes Care. 2006;29:2108–13.PubMedCrossRefGoogle Scholar
  32. 32.
    Duru OK, Mangione CM, Steers NW, et al. The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study. Med Care. 2006;44:1121–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Kim C, Williamson DF, Mangione CM, Safford MM, Selby JV, Marrero DG, Curb JD, Thompson TJ, Narayan KM, Herman WH. Translating Research Into Action for Diabetes (TRIAD) Study. Managed care organization and the quality of diabetes care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care. 2004;27:1529–34.PubMedCrossRefGoogle Scholar
  34. 34.
    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.PubMedCrossRefGoogle Scholar
  35. 35.
    D’Hoore W, Sicotte C, Tilquin C. Risk adjustment in outcome assessment: the Charlson comorbidity index. Methods Inf Med. 1993;32:382–7.PubMedGoogle Scholar
  36. 36.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715–22.PubMedCrossRefGoogle Scholar
  38. 38.
    Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987–93.PubMedCrossRefGoogle Scholar
  39. 39.
    Fox KA, Goodman SG, Klein W, Brieger D, Steg PG, Dabbous O, Avezum A. Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2002;23(15):1177–89.PubMedCrossRefGoogle Scholar
  40. 40.
    Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.CrossRefGoogle Scholar
  41. 41.
    Breslow NE, Clayton DG. Approximate inference in generalized linear mixed models. JASA. 1993;88:125–34.Google Scholar
  42. 42.
    Saddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Narayan KM. A diabetes report card for the United States:quality of care in the 1990s. Ann Intern Med. 2002;136:565–74.Google Scholar
  43. 43.
    Brown AF, Gregg EW, Stevens MR, Karter AJ, Weinberger M, Safford MM, Gary TL, Caputo DA, Waitzfelder B, Kim C, Beckles GL. Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Multicenter Study. Diabetes Care. 2005;28(12):2864–70.PubMedCrossRefGoogle Scholar
  44. 44.
    Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementing open access scheduling in primary care. A cautionalry tale. Ann Intern Med. 2008;148:915–22.PubMedGoogle Scholar
  45. 45.
    Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med. 2003;138:593–602.PubMedGoogle Scholar
  46. 46.
    UK Prospective Diabetes Study Group. White WB, Prisant LM, Wright JT Jr. Management of patients with hypertension and diabetes mellitus: advances in the evidence for intensive treatment. Am J Med. 2000;108:238–45.PubMedCrossRefGoogle Scholar
  47. 47.
    Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA. 2002;287:2542–51.Google Scholar
  48. 48.
    Duru OK, Mangione CM, Steers NW, et al. The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study. Med Care. 2006;44:1121–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Trivedi AN, Zaslavsky AM, Schneider EC, et al. Trends in quality of care and racial disparities in Medicare managed care. N Engl J Med. 2005;353:692–700.PubMedCrossRefGoogle Scholar
  50. 50.
    Solberg LI, Maciosek MV, Sperl-Hillen JM, Crain LA, Engebreston KI, et al. Does improved access to care affect utilization and costs for patients with chronic conditions. Am J Mang Care. 2004;10:717–22.Google Scholar
  51. 51.
    Piette JD. Perceived access problems among patients with diabetes in two systems of care. J Gen Intern Med. 2000;15:797–804.PubMedCrossRefGoogle Scholar
  52. 52.
    Rohrer JE, Bernard M, Naessens J, Kircher K, Adamson S. Impact of open access scheduling on realized access. Health Serv Manage Res. 2007;20:134–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Kerr EA, Smith DM, Hogan MH, et al. Comparing clinical automated, medical record and hybrid data sources for diabetes quality measures. Joint Comm J Qual Improv. 2002;28:555–65.Google Scholar
  54. 54.
    VA Office of Quality and Performance. 13 Feb 2001. Network Performance Measures Reports. http://vaww.oqp.med.va.gov/oqp_services/performance_measurement/reports.asp. Accessed 14 Apr 2003.
  55. 55.
    Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, et al. Improvements in diabetes processes of care and intermediate outcomes.: United States 1988-2002. Ann Intern Med. 2006;144:465–74.PubMedGoogle Scholar
  56. 56.
    Tuncelli et al. Endocr Pract. 2006;12(4):380–7.Google Scholar
  57. 57.
    Mainous AG, Koopman RJ, Gill JM, Baker R, Pearson WS. Relationship between continuity of care and diabetes control: evidence from the third national nutrition and examination surveys. Am J Public Health. 2004;94:66–70.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Usha Subramanian
    • 1
    • 2
    • 3
    • 8
  • Ronald T. Ackermann
    • 2
    • 3
  • Edward J. Brizendine
    • 4
  • Chandan Saha
    • 4
  • Marc B. Rosenman
    • 3
    • 5
  • Deanna R. Willis
    • 6
  • David G. Marrero
    • 3
    • 7
  1. 1.Roudebush VAMCIndianapolisUSA
  2. 2.Division of General Internal Medicine and Geriatrics, Department of MedicineIndiana University School of MedicineIndianapolisUSA
  3. 3.Regenstrief Institute for Healthcare, IncIndianapolisUSA
  4. 4.Division of Biostatistics, Department of MedicineIndiana University School of MedicineIndianapolisUSA
  5. 5.Department of PediatricsIndiana University School of MedicineIndianapolisUSA
  6. 6.Department of Family MedicineIndianapolisUSA
  7. 7.Division of Endocrinology, Department of MedicineIndiana University School of MedicineIndianapolisUSA
  8. 8.IF-122IndianapolisUSA

Personalised recommendations