Your doctor also should be informed of any changes in your diet, exercise , or medicines, and of any new illnesses you may have developed. Tell your doctor if you have experienced any symptoms of eye, nerve, kidney, or cardiovascular problems, such as:. At each visit, your weight and blood pressure should be measured. Your eyes, feet, and insulin injection sites should also be examined at each visit.
All patients with diabetes should see an ophthalmologist every year for a dilated eye examination--beginning at diagnosis in people with type 2 diabetes, and in 3 to 5 years in people with type 1 diabetes after puberty. Patients with known eye disease, symptoms of blurred vision in one eye, or blind spots may need to see their ophthalmologist more frequently.
Examining Office Visit Trends for Diabetes | Physician's Weekly
Women who have diabetes and become pregnant should have a comprehensive eye exam during the first trimester and close follow-up with an eye doctor during pregnancy this recommendation does not apply to women who develop gestational diabetes. Urine testing should be performed every year.
Regular blood pressure checks are important since control of hypertension high blood pressure is essential in slowing kidney disease. Persistent leg or foot swelling may be a symptom of kidney disease and should be reported to your doctor. Numbness, tingling, burning, or pain in your feet should be reported to your doctor at your regular visits.
Patients often become frustrated and dissatisfied if they feel that they are being judged and blamed for their inability or unwillingness to achieve medical goals, or if the physician does not consider their goals to be important. Once patients are viewed as collaborators who establish their own goals, the whole concept of compliance becomes irrelevant. When patients work toward their own goals, their motivation is intrinsic. Because true and lasting motivation comes from within, patients are able to make and sustain changes in their behavior using this patient-centered approach.
In our work with patient empowerment we have found that this orientation leads to effective care that eliminates the problem of noncompliance. There are at least 2 steps in this process. First, roles and responsibilities need to be redefined to match the reality of diabetes care.
Second, patients and physicians must create relationships that promote collaboration and partnership. We find that if physicians view themselves as experts whose job is to get patients to behave in ways that reflect that expertise, both will continue to be frustrated. However, when health professionals let go of the traditional view of provider-centered care and recognize the patient as the primary decision-maker, they become more effective practitioners.
This new vision has led to patient-provider relationships that are based on mutual expertise and responsibility. Once physicians recognize patients as experts on their own lives, they can add their medical expertise to what patients know about themselves to create a plan that will help patients to achieve their goals.
We found that when health professionals actively support patients' efforts to achieve their own goals, the resulting commitment and self-motivation leads to positive outcomes.
Assessing patients' goals, capabilities, priorities, skills, supports, and barriers puts them at the center of the interaction about disease management. One simple but powerful strategy is to start each visit by asking questions such as, "What are your concerns? So, what can we do about the problem of noncompliance? In our experience, once health professionals eliminate the idea of noncompliance from their vision and approach to patients, it disappears as a problem. The Problem With Compliance in Diabetes. All Rights Reserved.
What to expect when seeing a doctor for diabetes
However, office visits offer limited communication opportunities due to the priority that frequently must be placed on acute problems and because of the high volume of care-guidelines that must be addressed [ 1 , 2 ]. Due to the time limitations of office visits, the Institute of Medicine has listed healthcare communication outside office visits both by phone and online as a key rule for healthcare redesign as a way of supporting continuous patient—physician relationships [ 3 ] and increasing healthcare quality.
An accumulating body of evidence supports this recommendation by demonstrating that patients who communicate with their healthcare team between face to face visits, either by phone or by secure messaging, have generally better healthcare outcomes phone: [ 4—9 ]; online:[ 10 , 11 ]. Recent studies have suggested that physician communication behaviors may influence patients' willingness to communicate between office visits, particularly when it comes to online communication tools.
Weppner [ 12 ] and Ralston [ 10 ] both found that patients were more likely to use patient—physician secure email communication referred to as secure messaging if their primary care physician PCP was a frequent user of secure messaging. Combined with the evidence suggesting that between-visit communication improves individual healthcare outcomes, these data suggest that physicians' who use, and encourage their patients to use, out-of-office communication tools may provide higher quality patient care.
In this study, we used a physician-level analysis to evaluate the association between between-visit patient—physician communication and a key measure of the delivery of high-quality healthcare for patients with diabetes: the Diabetes Recognition Program DRP scores. We focused on care for patients with diabetes as it requires frequent communication between physician and patient and is likely to be positively affected by factors that increase patient—physician interactions. We chose DRP scores as our measure of panel-level quality as the final score consists of a roll-up of a variety of outcome and process measures, allowing us to separately estimate the association between out-of-office communication methods and outcome vs.
Although the Institute of Medicine does not distinguish between phone and online communications in its recommendations, we also considered whether the use of phone vs.
Examining Office Visit Trends for Diabetes
Phone contacts have been part of medical practice for many years to increase access and provide medical triage [ 4 , 13—15 ]. Secure messaging is a newer mode of patient—physician communication that is expected to increase healthcare efficiency and improve communication between patients and physicians [ 16—19 ]. Since its introduction there has been strong consumer demand for online communication with physicians [ 20—22 ], and there is some evidence that patients may be willing to discuss issues online that they may be too embarrassed to bring up in person or over the phone [ 23 ].
However, traditional phone-based care continues to play a large role in patient—physician communication as many physicians prefer phone communication to secure messaging [ 24 , 25 ], not all patients have access to the infrastructure required for online communication [ 26 ], and some patients continue to have security concerns [ 23 , 24 ]. Thus, in addition to assessing the overall relationship between out-of-office communication and DRP scores, we also evaluated the relationships between DRP scores and the use of phone and secure messaging separately to determine if the individual communication methods had different effects.
Finally, because race has been shown to have an effect on diabetes care and outcomes [ 27—29 ], face-to-face office visit communication [ 30—32 ], and the use of online tools [ 33 ], we explicitly examined how the relationship between out-of-office communication and DRP scores depended on the racial profile of the patient panel. We separated our physician population into two groups: one group consisted of physicians' whose patients were predominantly black or Hispanic, while the other group was composed of physicians whose patients had a more racially mixed profile.
This retrospective study compared the use of out-of-office communication secure messaging and phone calls with scores calculated for accreditation in the DRP while controlling for physician, patient and care center factors. KPMAS is an integrated delivery system that both insures and provides healthcare for over members at 30 locations. The physicians at KPMAS are compensated on a salary basis and thus have no financial incentives to require office visits to deliver care if that care can safely and effectively be provided through mechanisms other than in-person visits, such as secure messaging and phone calls.
The EMR contains patient information regarding primary and specialist care, outpatient surgery, lab services, radiology and pharmacy, as well as data from phone and secure messaging interactions. In addition, all patients have access to a secure password protected web-based personal health record PHR based on Epic System's MyChart system.
The PHR provides patient—physician secure messaging, as well as patient access to laboratory and pharmacy information and online appointment scheduling. Data for this study were obtained from three sources: a data warehouse Clarity that contains an extract of the EMR and PHR data, a separate data warehouse that indicates which prescriptions were picked up by patients, and claims data for care provided external to the delivery system.
When measuring diabetes patient panel size, we included only patients who were registered with the PCP throughout the study time period. Two or more outpatient ICD9 code of A dispensing record for an oral hypoglycemic excludes Metformin, Exenatide, Pioglitazone, Rosiglitazone or Repaglanide only or insulin OR. Female member coded for polycystic ovary syndrome and identified by Metformin, Pioglitazone or Rosiglitazone only OR.
Female member with a positive pregnancy test OR code for gestational diabetes XX is temporarily excluded from the diabetes population for 18 months after the positive pregnancy test date or date of code OR. Member with oral steroid Rx OR coded for pre-diabetes We used DRP scores to estimate how well individual doctors care for their entire practice of patients with diabetes.
The National Committee for Quality Assurance DRP program assesses performance on 10 clinical indicators including both outcome and process metrics, as listed in Appendix 1 [ 34 ], which are combined to produce one overall DRP score that ranges from 0 to The time period for analysis was 1 January to 31 December For each selected patient, we noted the value of the most recent HbA1C, LDL and BP recorded within that time frame and calculated the proportion of values above or below the cut-off values for each physician. Scores on the individual metrics were summed. To evaluate how DRP scores are related to out-of-office care, we focused on two forms of out-of-office communication: the use of secure messaging and the use of phone calls for interactions between patients and PCPs.
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To estimate the use of secure messaging within a given PCP's diabetes patient panel, we measured the proportion of the PCP's diabetes patients that had one or more secure message interactions with the physician, regardless of whether the secure message was initiated by the patient or the provider. We chose not to restrict the analysis to physician-initiated secure messages as KPMAS physicians frequently request that their patients send them information by secure message between visits.
Thus, a secure message initiated by a patient could have been prompted by the physician's request during an office visit, making it difficult to determine who truly initiated the interaction. For descriptive purposes, we also measure what proportion of the patient panel has registered for kp. Registration for kp. To measure the frequency of phone interactions between physicians and their diabetes patients, we tracked the number of phone encounters in the EMR linked to both the patient and the PCP.
We then calculated both the proportion of each diabetes patient panel that interacted with the physician by phone at least once during the time period of interest. Only secure messages and phone calls directed to the healthcare team rather than administrative or urgent care staff were included in the analysis.
No distinction was made between secure messages that contained clinically oriented interactions and those that contained more general interactions such as requests for refills. However, patients could schedule appointments and request renewals of medications electronically using specific portal functions without sending secure messages. These types of interactions were not counted as messages. We also evaluated the use of any communications outside of office visits secure messaging or phone by measuring the proportion of the physicians' diabetes patient panels that used any combination of phone and secure messaging to interact with their physicians.
Because physicians were not randomly assigned to a communication method, additional unobserved factors may have influenced both the use of out of office communication methods and the physicians' DRP scores. We considered three types of factors that might influence both physician—patient communication methods and physician DRP scores: care center characteristics, physician characteristics and patient characteristics. Prior research has shown that patients in rural areas may have poorer health outcomes than patients in urban areas [ 35 ]. In addition, patients in rural areas who have to travel further to see their doctor face to face may be more likely to use out-of-office communication methods with their physicians.
Thus, the locale of the care center may impact the observed relationship between communication methods and physician scores. We used the population density in the care center's zip code as a proxy for determining whether the physician practiced in an urban, suburban or rural environment. Based on previous examinations of secure messaging adoption, younger physicians may be more willing to use less traditional methods of communication such as secure messaging [ 36 ].
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A preliminary correlation analysis also indicated a relationship between physician age and DRP scores. Thus, we included physician age as a covariate in the analysis of the relationship between communications methods and DRP scores. In addition, the number of patients physicians care for may impact their availability for out of office communications [ 36 ], as well as the level of care they are able to provide, leading us to include total panel size as a covariate.
Although physicians are the primary unit of analysis in this paper, DRP scores ultimately measure the health and health behaviors of the physicians' patients. While a physician can influence these characteristics, patient outcomes and care processes also depend largely on characteristics of the patients themselves, such as their overall health.
Accordingly, we measured the average number of comorbid conditions for the patient panel, where comorbid conditions consisted of the following diagnoses registered in the POINT population management database: asthma, coronary artery disease, cardiovascular disease, chronic kidney disease, hypertension and osteoporosis. In addition, we calculated the average number of in-person PCP doctor's office visits for the diabetes patients on each physician panel.
In addition, considerable research has shown that patient demographic characteristics may be strongly related to both diabetes outcomes [ 29 ] and patient—physician communication [ 10 , 12 , 30 , 37 ].
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Thus, if there are significant differences in the demographics between the physicians' panels, those differences may influence the observed correlation between out-of-office communication and DRP scores. We evaluated three major demographic characteristics of each patient panel: average age, racial profile and economic profile.