title: Global health care use by patients with type-2 diabetes: Does the type of comorbidity matter?
abstract: OBJECTIVE
  To identify patterns of health care use among diabetic patients with multimorbidity across primary, specialised, hospital and emergency care, depending on their type of chronic comorbidity.
  
  
  METHODS
  Longitudinal study of a population-based retrospective cohort conformed by adult patients with type-2 diabetes assigned to any of the primary care centres in Aragon during 2010 and 2011 (n=65,716). Negative binomial regressions were run to model the effect of the type of comorbidity on the number of visits to each level of care. Comorbidities were classified as concordant, discordant or mental based on expert consensus and depending on whether they shared the same overall pathophysiologic risk profile and disease management plan designed for type-2 diabetes.
  
  
  RESULTS
  Mental comorbidity was independently associated with total and unplanned admissions (incidence rate ratio [IRR]:1.25; 95% confidence interval [CI]:1.12-1.39, IRR:1.21; 95% CI:1.06-1.39), average length of stay (IRR:1.47; 95% CI:1.25-1.73), and total and priority emergency room visits (IRR:1.26; 95% CI:1.17-1.35, IRR:1.30; 95% CI:1.18-1.42). Patients with discordant comorbidities showed the strongest associations with the number of visits to specialists (IRR:1.38; 95% CI:1.33-1.43) and to different specialties (IRR:1.36; 95% CI:1.32-1.39). Differences regarding GP visits were lower but still significant for patients with discordant comorbidity (IRR:1.08; 95% CI:1.06-1.11), but especially for those with mental comorbidity (IRR:1.17; 95% CI:1.14-1.21).
  
  
  CONCLUSIONS
  In patients with type-2 diabetes, the coexistence of mental comorbidity significantly increases the use of unplanned hospital services, and discordant comorbidities have an important effect on specialised care use. Differences with respect to primary care use are not as prominent.
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain. Electronic address: acalderon.iacs@aragon.es.
authors.forename: A
authors.initials: A
authors.lastname: Calderón-Larrañaga
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; Dept. of Health, Welfare and Family, DG Planning and Assurance, Government of Aragon, Vía Univérsitas 36, 50009 Zaragoza, Spain.
authors.forename: J M
authors.initials: JM
authors.lastname: Abad-Díez
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; San Pablo Health Centre, Aragon Health Service (SALUD), C/Aguadores 7, 50003 Zaragoza, Spain.
authors.forename: L A
authors.initials: LA
authors.lastname: Gimeno-Feliu
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; Miguel Servet University Hospital, Department of Neurology, Aragon Health Service (SALUD), Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Marta-Moreno
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; Delicias Sur Health Centre, Aragon Health Service (SALUD), C/Manuel Dronda 1, 50009 Zaragoza, Spain.
authors.forename: F
authors.initials: F
authors.lastname: González-Rubio
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; Socio-Sanitary Assessment Unit, Miguel Servet University Hospital, Aragon Health Service (SALUD), Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain.
authors.forename: M
authors.initials: M
authors.lastname: Clerencia-Sierra
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain.
authors.forename: B
authors.initials: B
authors.lastname: Poblador-Plou
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain; Zaragoza-Sector III Primary Care Directorate, Aragon Health Service (SALUD), C/Condes de Aragón 30, 50009 Zaragoza, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Poncel-Falcó
authors.affiliation: EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragon, Miguel Servet University Hospital, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Prados-Torres
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D057286:Electronic Health Records; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012189:Retrospective Studies; D055815:Young Adult
keywords: Electronic health records; Emergency care; Hospitalization; Multimorbidity; Primary health care