An understanding of health care utilization as well as self-care and health behaviors is critical in designing interventions to improve diabetes care in older adults. This information has been lacking for underserved adults. A strength of the study is the in person survey that provided information not available in other data sets. Additionally, this is one of the few studies with a large ethnically diverse sample from urban and rural areas.
Despite major differences in terms of educational level, insurance status, and ethnicity between the national and underserved groups, most usage levels were similar for inpatient care and physician visits. While this result could be interpreted as equal levels of care, it could also be interpreted as worse care for the underserved because they report poorer health status. There were some significant differences, however, the underserved did report somewhat higher numbers of emergency visits and substantially more physical therapy and home health visits but substantially fewer nonphysician provider visits. It is possible that some of these differences, particularly the reports of nonphysician provider visits, stem from differences in how these data were collected, namely from claims data in MEPS and from self-report in IDEATel.
Self-care is critical for good diabetes outcomes. Seven percent of the underserved reported not measuring their blood glucose levels at all, but among insulin users, for whom blood glucose measurement is most important, only 2% (a fraction not statistically significantly different from zero) reported not measuring their blood glucose at all. Twenty percent reported measuring their blood glucose less than once a day, and only 33% reported measuring their blood glucose more than once a day. On average, the underserved reported spending 28 minutes per day on their diabetes, a good sign for improving their health outcomes but hardly an inconsequential burden. Respondents also reported considerable time spent waiting for and traveling to appointments. Finally, the care of nutritionists and diabetes educators is thought to be valuable to help those with diabetes to improve their self-care; it was striking that the underserved group reported very little care provided by nutritionists or diabetes educators. This is not unexpected because dietitians and educators are not readily available in medically underserved areas.
The mean monthly out-of-pocket expenses for the underserved group were relatively modest at $4.29. In contrast, for the general population older than age 65, mean monthly out-of-pocket prescription drug expenses were about $48 in 2003.25
While the comparatively low out-of-pocket spending may be due to poor recall in self-reports, it may reflect an effective safety net. Because evidence suggests that significant cost-sharing can hurt the health of the chronically ill,26
the low out-of-pocket spending is reassuring to the extent that it reflects low cost-sharing for those with diabetes.
Among the underserved, the urban group reported more use of inpatient and emergency department care, perhaps because they are in closer proximity to hospitals. They also reported more use of transportation services, again perhaps due to availability. The urban group reported worse general health status and more ADL impairment. They also reported substantially more use of home health care, possibly due to a higher rate of Medicaid coverage. From the IDEATel cross-sectional data, it was not clear the extent to which truly higher levels of functional impairment drove the greater use of home health care in the urban group among the underserved. It is also possible that greater use of home health care drove greater reporting of impairments by contributing to a perception of impairment or need to justify the assistance. In the critical areas of self-care, particularly blood glucose measurement, the urban group had worse performance. The most striking finding is that, on average, differences between the urban and nonurban groups, who are also minority and majority groups, are much greater than those between the underserved and nationally representative groups. Health care service use has been reported to differ in Hispanics and non-Hispanics, even within facilities.27
Given the ethnic differences between the urban and rural groups in IDEATel, this study cannot determine if differences between these urban and rural groups were due to geographic or ethnic differences.
A limitation of this study is that the sample was not random and may not be representative of underserved Medicare beneficiaries with diabetes. As shown, IDEATel participants had low average income and resided in medically underserved areas. The nonurban (upstate) sample may generalize to low income geographic regions with lower levels of public services and poor or no public transportation. The urban sample may generalize to low-income individuals of Latino and African American or black descent, living in NYC. It is emphasized that the data reported for the underserved group is not intended to be representative of all the medically underserved, but represents low-income people with diabetes living in medically underserved areas. As in all studies, those willing to participate in a study or survey may differ from the broader population. A further limitation of this study is that it is descriptive and cannot determine the causes of differences. Rather the study reveals what differences do and do not exist—valuable information for policy makers and practitioners.
The findings presented address a gap in knowledge about older individuals with diabetes because they focused on the medically underserved, including a substantial number of minority group members. Moreover, despite the limitation inherent in self-reported data, information about services not included in claims data, such as community-based home care, care provided by unpaid informal sources, and self-care, were presented. These data will be of use to educators and policy planners seeking a profile of service use and health care practices among medically underserved and minority elderly individuals with diabetes living in urban and rural areas to help direct future programs to improve care.