Quality of care provided to patients with diabetes mellitus in Puerto Rico; managed care versus fee-for-service experience.
OBJECTIVE
To evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico.


METHODS
This retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects--226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed.


RESULTS
From the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A lc testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits.


CONCLUSIONS
The quality of diabetes management and the subsequent outcomes are related to patient and health-care provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes.
Rodríguez-Vigil
Efraín
E
Center for Diabetes Control Inc., Sánchez Osorio Avenue #5A3, Villa Fontana, Carolina, Puerto Rico 00983.
Kianes-Pérez
Zaira
Z
D000368:Aged; D003430:Cross-Sectional Studies; D048909:Diabetes Complications / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D018588:Fee-for-Service Plans / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006282:Health Personnel / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007755:Laboratories, Hospital / Q000706:statistics & numerical data; D008297:Male; D008329:Managed Care Programs; D008875:Middle Aged; D010821:Physicians, Family / Q000706:statistics & numerical data; D011647:Puerto Rico; D011787:Quality of Health Care; D012189:Retrospective Studies