Short Communication

Diabetes and the use of primary care provider services in rural, remote and metropolitan Australia

AUTHORS

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Soumya Mazumdar1
PhD, Adjunct Senior Lecturer and Epidemiologist *

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Nasser Bagheri2
PhD, Senior Research Fellow

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Shanley Chong3
PhD, Adjunct Senior Lecturer and Biostatistician

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Ian S McRae4
PhD, Visiting Fellow

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Bin Jalaludin5
FAFPHM, PhD, Manager

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Federico Girosi6
PhD, Professor

CORRESPONDENCE

*Dr Soumya Mazumdar

AFFILIATIONS

1 South Western Sydney Medical School, University of New South Wales, NSW 2170, Australia; and Population Health Intelligence, South Western Sydney Local Health District, Liverpool, NSW 1871, Australia

2 College of Health and Medicine, Australian National University, Canberra, ACT 0200, Australia

3 Population Health Intelligence, South Western Sydney Local Health District, Liverpool, NSW 1871, Australia and South Western Sydney Medical School, University of New South Wales, NSW 2170, Australia

4 Department of Health Services Research & Policy, Australian National University, Canberra, ACT 0200, Australia

5 Population Health Intelligence, South Western Sydney Local Health District, Liverpool, NSW 1871, Australia

6 Translational Health Research Institute, Western Sydney University, Campbelltown, NSW 2560, Australia

PUBLISHED

2 August 2021 Volume 21 Issue 3

HISTORY

RECEIVED: 28 January 2020

REVISED: 11 May 2021

ACCEPTED: 20 May 2021

CITATION

Mazumdar S, Bagheri N, Chong S, McRae IS, Jalaludin B, Girosi F.  Diabetes and the use of primary care provider services in rural, remote and metropolitan Australia. Rural and Remote Health 2021; 21: 5844. https://doi.org/10.22605/RRH5844

AUTHOR CONTRIBUTIONSgo to url

This work is licensed under a Creative Commons Attribution 4.0 International Licence


abstract:

Introduction:  Public health agencies around the world are concerned about an ever-increasing burden of type 2 diabetes and related disability. Access to primary care providers (PCPs) can support early diagnosis and management. However, there is limited literature on how frequently older people with diabetes access PCPs, and their levels of access in rural Australia relative to metropolitan areas.
Methods:  In this research, patterns of PCP use among those with diagnosed diabetes and those without diagnosed diabetes (referred to as ‘healthy’ individuals) were compared using a large survey of more than 230 000 people aged 45 years and older from New South Wales, Australia. A published model to study the PCP access patterns of a group of individuals with diabetes risk was used.
Results:  Annual visits to PCPs among people aged 45 years or more with diabetes in rural areas, while higher than for healthy rural residents, were significantly lower than their metropolitan counterparts, mirroring similar disparities in PCP use across the rural–urban divide in the healthy population. Similar patterns were present in the high–risk population. Nevertheless, people with diabetes visited PCPs around four times a year, which is around the recommended number of annual visits, although some groups (eg those with comorbidities) may need more visits.
Conclusion:  Patterns of PCP use among rural residents, while significantly less frequent than their metropolitan counterparts, are at the recommended level for people with diabetes.

Keywords:

Australia, diabetes mellitus, health services accessibility, geographic accessibility, healthcare disparities, primary care, rural health services, diagnosis.

full article:

Introduction

Primary care providers (PCPs) or general practitioners (GPs), along with other primary care practitioners such as nurses, provide the bulk of care for people with diabetes in developed countries with large rural hinterlands like the USA, Canada and Australia. A limited number of studies have investigated access to PCP services among people with diabetes in rural areas in these countries, and few have addressed how individuals at high risk of diabetes access PCP services across the rural–urban divide1.

The goal of the research reported here was to investigate use of PCP services among people with diabetes and people at risk of diabetes using a large survey of people aged 45 years or more (referred to herein as ‘older’ people) linked to PCP use data. Our primary research question asked ‘How different are the access patterns (number of PCP visits) of older people with diabetes and older people at high risk of diabetes in rural Australia from their 'healthy' (without or at risk of diabetes) and metropolitan counterparts?’

Methods

Data

Data were from the 45 and Up Study, a baseline survey of more than 267 112 people aged 45 years or more from New South Wales (NSW), Australia. The survey, mostly administered around 2008, by the Sax Institute, randomly sampled approximately 10.9% of the older population in NSW using the Department of Human Services enrolment database, which provides near-complete coverage of the population2. People aged 80 years or more and residents of regional and remote areas were oversampled by a factor of two. These survey data were linked by the Sax Institute using a unique Department of Human Services identifier to Medicare Benefits Schedule PCP administrative claims data (number of PCP visits made by respondents) and subset to a 6 month window before and after the survey date.

Information was obtained about each survey respondent’s postcode of residence, age, sex, country of birth, highest qualification, whether they were ever told by a doctor that they had hypertension or high cholesterol, whether they had familial heart diseases, the hours they spent sitting or sleeping, their body mass index and smoking patterns (Tables 1, 2). Diabetes status was inferred from the survey question ‘Has a doctor ever told you that you have diabetes?’, which has been previously validated against external diabetes data3. The postcode was attached to Australian Statistical Geographic Standard rurality codes, which divide the land mass of Australia into five categories with increasing degrees of rurality: metropolitan, inner regional, outer regional, remote and very remote. Of 267 112 respondents, 35 117 were missing various covariates, resulting in a sample of 231 995 (Tables 1, 2).

Table 1:  Basic demographic information for study population table image

Table 2:  Health and behavioural characteristics of study populationtable image

Categorising respondents

The authors tabulated the average number of PCP visits by metropolitan, regional (both inner and outer) and remote/very remote across three mutually exclusive categories: people with diabetes, healthy respondents and those with diabetes risk factors. The methods of identifying the group with risk factors of diabetes, utilising a previously published model4 are described in Appendix I.

Ethics approval

The Sax Institute’s 45 and Up Study was approved by the University of NSW Human Research Ethics Committee. The project was approved by the NSW Population and Health Services Research Ethics Committee (HREC/13/CI/CIPHS/8).

Results

People with diabetes in regional areas made significantly fewer PCP visits than people with diabetes in metropolitan areas (Fig1), although they visited PCPs more regularly than their healthy counterparts in regional areas. Thus, while regional people with diabetes made an average of 0.6 fewer visits annually than their metropolitan counterparts they also made 1.6 more visits annually than healthy individuals in regional areas. People with diabetes in metropolitan areas, in contrast, made 1.75 more visits annually than their healthy counterparts. Indeed, across the board, people in metropolitan areas made more visits, reflecting better access. Those at high risk of diabetes made an intermediate (between healthy people and people with diabetes) number of visits. Large confidence intervals for summary statistics, owing to small numbers from remote/very remote areas, made inferences difficult.

table image Figure 1:  Primary care provider visits among the reference population, people with diabetes and people with undiagnosed diabetes across rurality and socioeconomic gradients.

Discussion

Access to health services in regional and remote areas is a problem. This study investigated PCP access in older rural people with diabetes – an especially vulnerable group – using data from a large survey from NSW, Australia. The authors found that while people with diabetes living in rural areas visit PCPs less often than comparable groups, they still make about four visits each year, the recommended number for people with diabetes5-7, although it is not known whether the visits are diabetes-related. Older people with diabetes may have comorbid conditions requiring more than the recommended four annual visits. Guidelines regarding recommended number of visits for specific groups – such as older people in rural areas with diabetes – are sparse, and it is likely that they may need more than four visits a year.

A group identified as having many of the risk factors of diabetes visited PCPs relatively often (about four visits each year). This may be because of existing illnesses – some of which (eg high blood pressure) are incorporated in the risk index, and some of which are associated with other risk factors – but again shows similar urban–rural gradient of access, with rural residents making around one fewer visit each year than their metropolitan counterparts. Thus, even if this model of diabetes risk prediction is not accurate, the fact that individuals in rural Australia may be less able to access PCP support to help in the management of their risk factors is a cause for concern.

The authors were unable to find any studies that investigated patterns of PCP use among people at risk of diabetes, but some studies have investigated patterns of PCP use among people with diabetes, reporting rates of use similar to the ones reported here. A study from the USA reported that, in 2011, approximately half of all people with diabetes had six or more office-based physician (who may include specialists) visits annually8. A study from Western Australia reported PCP usage levels among people with diabetes that range from around 2 visits in 10 months to 8 visits in 40 days9. The present results are somewhere between these extremes reported in the Western Australia study.

Conclusion

The strength of this study is that it utilises linked data from a large survey. A weakness of this study is that the survey did not include any clinical data, which may have been used for better risk prediction and analysis and for identifying specifically diabetes-related visits. Nevertheless, it is hoped that this study will stimulate research on PCP access for people with diabetes in rural areas with better quality data.

Acknowledgements

This research was initiated at the Australian Primary Health Care Research Institute, which was a key component of the Australian Government funded Primary Health Care Research, Evaluation and Development (2000–2014) Strategy. This research was completed using data collected through the 45 and Up Study (www.saxinstitute.org.au). The 45 and Up Study is managed by the Sax Institute in collaboration with major partner Cancer Council NSW, and partners: the National Heart Foundation of Australia (NSW Division); NSW Ministry of Health; NSW Government Family & Community Services – Ageing, Carers and the Disability Council NSW; and the Australian Red Cross Blood Service. We thank the many thousands of people participating in the 45 and Up Study.

references:

1 Unger C, Warren N, Canway R, Manderson L, Grigg K. Type 2 diabetes, cardiovascular disease and the utilisation of primary care in urban and regional settings. Rural and Remote Health 2011; 11(4): 1795. DOI link, PMid:22084841
2 45 and Up Study collaborators. Cohort profile: the 45 and Up Study. International Journal of Epidemiology 2008; 37(5): 941. DOI link, PMid:17881411
3 Comino EJ, Tran DT, Haas M, Flack J, Jalaludin B, Jorm L, et al. Validating self-report of diabetes use by participants in the 45 and Up Study: a record linkage study. BMC Health Services Research 2013; 13(1): 481. DOI link, PMid:24245780
4 Ding D, Chong S, Jalaludin B, Comino E, Bauman AE. Risk factors of incident type 2-diabetes mellitus over a 3-year follow-up: results from a large Australian sample. Diabetes Research and Clinical Practice 2015; 108(2): 306-315. DOI link, PMid:25737033
5 Mayo Clinic. Diabetes care: 10 ways to avoid complications. Available: web link (Accessed 4 March 2021).
6 National Diabetes Services Scheme. You and your health care team. Canberra: National Diabetes Services Scheme, 2018.
7 Royal Australian College of General Practitioners and Diabetes Australia. Management of type 2 diabetes: a handbook for general practice. Melbourne: Royal Australian College of General Practitioners and Diabetes Australia, 2020.
8 McEwen LN, Herman WH. Health care utilization and costs of diabetes. In: CC Cowie, SS Casagrande, A Menke, MA Cissell, MS Eberhardt, JB Meigs, et al (Eds). Diabetes in America. 3rd edn. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, 2018.
9 Ha NT, Harris M, Preen D, Robinson S, Moorin R. Identifying patterns of general practitioner service utilisation and their relationship with potentially preventable hospitalisations in people with diabetes: the utility of a cluster analysis approach. Diabetes Research and Clinical Practice 2018; 138: 201-210. DOI link, PMid:29432773

appendix I:

Method of identifying a group with risk factors of diabetes

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Table A1: Weights of the various risk factors of diabetes used in the model table image

Table A2: Exploring characteristics of people with risk factors of diabetes, diagnosed diabetes and everyone else (reference)

table image