title: No moment wasted: the primary-care visit for adults with diabetes and low socio-economic status.
abstract: OBJECTIVE
  To better understand the type and range of health issues initiated by patients and providers in 'high-quality' primary-care for adults with diabetes and low socio-economic status (SES).
  
  
  BACKGROUND
  Although quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care.
  
  
  METHODS
  We conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009-2010. Findings In a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13-32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior.
  
  
  CONCLUSIONS
  Primary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients.
authors.affiliation: 1Department of Medicine,Center for Health Care Research and Policy,Case Western Reserve University,MetroHealth Medical Center,Cleveland,Ohio,USA.
authors.forename: Shari D
authors.initials: SD
authors.lastname: Bolen
authors.affiliation: 3Department of Sociology,Case Western Reserve University,Cleveland,Ohio,USA.
authors.forename: Paulette
authors.initials: P
authors.lastname: Sage
authors.affiliation: 1Department of Medicine,Center for Health Care Research and Policy,Case Western Reserve University,MetroHealth Medical Center,Cleveland,Ohio,USA.
authors.forename: Adam T
authors.initials: AT
authors.lastname: Perzynski
authors.affiliation: 2Department of Epidemiology and Biostatistics,Case Western Reserve University,Cleveland,Ohio,USA.
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Stange
mesh_terms: D000328:Adult; D003920:Diabetes Mellitus / Q000517:prevention & control / Q000628:therapy*; D005260:Female; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D008297:Male; D009820:Ohio; D011203:Poverty; D011320:Primary Health Care / Q000379:methods*; D012959:Socioeconomic Factors
keywords: diabetes; primary care; qualitative research