Article Figures & Tables
Figures
- Figure 1
Cohort selection for patients with diabetes included in the analysis.
Tables
- Table 1: Baseline patient and network characteristics as of Apr. 1, 2009, stratified by rurality and primary care physician supply for study population (n = 712 681)
Characteristics Urban
primary care physician supplyNonurban
primary care physician supplyLow (n = 199 534) Medium (n = 217 955) High (n = 169 853) Low (n = 27 694) Medium (n = 22 370) High (n = 75 275) Network characteristics Primary care physician FTE per 100 000 Median (IQR) 63.00 (3.00) 66.79 (3.12) 72.05 (4.47) 61.04 (6.64) 69.03 (3.46) 74.89 (8.11) Range 59.0-64.0 64.2-70.3 70.4-82.4 57.2-64.1 64.6-69.3 71.5-92.5 Primary care physician loyalty Median (IQR) 78.02 (3.59) 81.48 (13.96) 80.56 (12.30) 90.83 (8.40) 87.62 (2.91) 91.00 (6.71) Range 71.8-95.9 71.5-95.6 61.9-90.7 83.4-95.2 79.6-89.0 81.3-94.7 Endocrinologist FTE per 100 000 Median (IQR) 0.93 (0.76) 1.28 (0.90) 2.37 (3.32) 0.00 (0.99) 0.00 (0.00) 0.74 (1.29) Range 0.0-2.9 0.0-5.2 0.0-31.9 0.0-4.2 0.0-0.0 0.0-1.6 General internal medicine FTE per 100 000 Median (IQR) 4.56 (3.82) 6.76 (5.11) 7.29 (10.48) 8.32 (3.00) 7.56 (3.78) 5.72 (3.02) Range 2.8-25.8 2.7-18.0 2.4-27.5 5.9-12.2 4.7-11.2 3.1-9.0 Cardiologist FTE per 100 000 Median (IQR) 3.79 (3.29) 3.07 (1.47) 8.76 (11.09) 0.00 (2.74) 0.01 (2.03) 3.31 (5.12) Range 1.3-8.6 1.3-8.0 2.1-20.9 0.0-2.8 0.0-4.8 0.0-8.1 No. of ophthalmologists per 100 000 Median (IQR) 2.27 (2.39) 3.17 (4.41) 3.62 (4.13) 1.92 (1.20) 2.09 (1.82) 2.84 (1.23) Range 0.5-4.0 0.0-9.6 1.1-25.0 1.4-3.8 0.0-3.0 0.0-8.7 No. of optometrists per 100 000 Median (IQR) 12.40 (3.59) 15.50 (2.11) 14.55 (8.46) 15.95 (1.29) 17.15 (2.80) 16.89 (7.88) Range 7.8-21.2 2.0-27.4 0.0-20.0 13.9-20.2 14.1-25.0 9.9-21.8 No. of hospital beds per 100 000 Median (IQR) 0.89 (0.32) 1.10 (0.65) 1.84 (1.63) 1.58 (0.25) 1.44 (0.41) 1.70 (0.84) Range 0.6-2.4 0.7-2.2 0.9-7.0 1.2-1.8 0.9-2.0 1.2-2.6 Physician characteristics Patient age, yr, no. (%) 40-65 114 388 (57.3) 119 187 (54.7) 90 075 (53.0) 13 913 (50.2) 10 942 (48.9) 38 132 (50.7) 66-85 79 523 (39.9) 91 003 (41.8) 73 327 (43.2) 12 719 (45.9) 10 484 (46.9) 34 407 (45.7) > 85 5 623 (2.8) 7 765 (3.6) 6 451 (3.8) 1 062 (3.8) 944 (4.2) 2 736 (3.6) Male, % 105 537 (52.9) 114 602 (52.6) 88 836 (52.3) 14 886 (53.8) 12 081 (54.0) 40 432 (53.7) Income quintile, no. (%) 1 (lowest) 44 591 (22.3) 46 797 (21.5) 36 927 (21.7) 6 092 (22.0) 4 544 (20.3) 16 098 (21.4) 2 45 596 (22.9) 46 836 (21.5) 36 539 (21.5) 5 804 (21.0) 4 510 (20.2) 15 676 (20.8) 3 42 392 (21.2) 45 079 (20.7) 30 174 (17.8) 5 805 (21.0) 4 864 (21.7) 14 911 (19.8) 4 38 647 (19.4) 41 258 (18.9) 31 468 (18.5) 5 570 (20.1) 4 723 (21.1) 15 777 (21.0) 5 (highest) 27 795 (13.9) 36 738 (16.9) 33 800 (19.9) 4 096 (14.8) 3 689 (16.5) 12 438 (16.5) Missing, no. (%) 513 (0.3) 1 247 (0.6) 945 (0.6) 327 (1.2) 40 (0.2) 375 (0.5) Recent OHIP registrant, no. (%) 10 710 (5.4) 8 320 (3.8) 4 038 (2.4) 341 (1.2) 147 (0.7) 662 (0.9) Diabetes duration, yr, no. (%) 2-3 41 171 (20.6) 46 724 (21.4) 34 125 (20.1) 5 317 (19.2) 4 445 (19.9) 14 698 (19.5) 4-9 82 550 (41.4) 89 042 (40.9) 71 184 (41.9) 11 119 (40.1) 9 056 (40.5) 30 871 (41.0) 10-14 41 264 (20.7) 44 885 (20.6) 34 567 (20.4) 5 859 (21.2) 4 671 (20.9) 15 992 (21.2) ≥ 15 34 549 (17.3) 37 304 (17.1) 29 977 (17.6) 5 399 (19.5) 4 198 (18.8) 13 714 (18.2) Mental health diagnosis, no. (%) None 146 558 (73.5) 156 771 (71.9) 121 071 (71.3) 21 090 (76.2) 17 446 (78.0) 57 765 (76.7) Nonpsychotic 50 521 (25.3) 57 926 (26.6) 45 756 (26.9) 6 160 (22.2) 4 597 (20.5) 16 355 (21.7) Psychotic 2 455 (1.2) 3 258 (1.5) 3 026 (1.8) 444 (1.6) 327 (1.5) 1 155 (1.5) Number of ADGs*, no. (%) 0 1 775 (0.9) 1 942 (0.9) 1 481 (0.9) 201 (0.7) 196 (0.9) 671 (0.9) 1 5 469 (2.7) 7 232 (3.3) 5 612 (3.3) 1 066 (3.8) 908 (4.1) 3 134 (4.2) 2-5 67 924 (34.0) 77 730 (35.7) 59 740 (35.2) 9,942 (35.9) 8 654 (38.7) 29 255 (38.9) 6-10 92 061 (46.1) 96 252 (44.2) 74 374 (43.8) 11 949 (43.1) 9 343 (41.8) 31 784 (42.2) ≥ 11 32 305 (16.2) 34 799 (16.0) 28 646 (16.9) 4,536 (16.4) 3 269 (14.6) 10 431 (13.9) RUB†, no. (%) 0 1 775 (0.9) 1 942 (0.9) 1 481 (0.9) 201 (0.7) 196 (0.9) 671 (0.9) 1 824 (0.4) 1 060 (0.5) 756 (0.4) 120 (0.4) 105 (0.5) 314 (0.4) 2 13 277 (6.7) 16 222 (7.4) 12 279 (7.2) 2 192 (7.9) 1 951 (8.7) 5 994 (8.0) 3 118 296 (59.3) 124 170 (57.0) 95 418 (56.2) 14 732 (53.2) 12 228 (54.7) 41 294 (54.9) 4 41 809 (21.0) 45 473 (20.9) 36 208 (21.3) 6 024 (21.8) 4 587 (20.5) 15 683 (20.8) 5 23 553 (11.8) 29 088 (13.3) 23 711 (14.0) 4 425 (16.0) 3 303 (14.8) 11 319 (15.0) Note: ADG = adjusted diagnosis group, FTE = full time equivalent, IQR = inter-quartile range, OHIP = Ontario Health Insurance Plan, RUB = resources utilization band.
*General measure of comorbidity generated by the Johns Hopkins ACG Case-Mix System. A higher number of ADGs represents higher comorbidity.
†Measure of health care use generated by the Johns Hopkins Adjusted Clinical Group Case-Mix System. A higher number represents greater health care use.
- Table 2: Outcomes between Apr. 1, 2009, to Mar. 31, 2011, stratified by rurality and primary care physician supply
Outcome Patients, no. (%) Urban Nonurban Low Medium High Low Medium High Evidence-based testing (n = 621 692) Retinal eye examination 130 627 (70.8) 139 644 (71.7) 106 120 (72.5) 9 172 (77.5) 11 194 (77.4) 44 963 (76.8) Cholesterol test 164 171 (89.0) 170 794 (87.7) 127 818 (87.4) 9 947 (84.0) 12 785 (88.4) 50 931 (87.0) HbA1C test 0 26 014 (14.1) 29 285 (15.0) 22 613 (15.5) 1 833 (15.5) 1 864 (12.9) 8,107 (13.8) 1-3 81 639 (44.2) 81 517 (41.8) 60 042 (41.0) 4 889 (41.3) 5 190 (35.9) 21 180 (36.2) ≥ 4 76 852 (41.7) 84 014 (43.1) 63 628 (43.5) 5 118 (43.2) 7 404 (51.2) 29 252 (50.0) Optimal monitoring* 64 308 (34.9) 70 134 (36.0) 53 836 (36.8) 4 352 (36.8) 6 284 (43.5) 25 065 (42.8) Hospital visits for diabetes complications† (n = 756 597) Hospital admissions 0 189 465 (95.0) 206 006 (94.5) 160 396 (94.4) 25 559 (92.3) 20 689 (92.5) 69 976 (93.0) 1 7 166 (3.6) 8 507 (3.9) 6 706 (4.0) 1 525 (5.5) 1 186 (5.3) 3 829 (5.1) 2 1 809 (0.9) 2 142 (1.0) 1 661 (1.0) 362 (1.3) 304 (1.4) 905 (1.2) ≥ 3 1 094 (0.5) 1 300 (0.6) 1 090 (0.6) 248 (0.9) 191 (0.9) 565 (0.8) ≥ 1 10 069 (5.0) 11 949 (5.5) 9 457 (5.6) 2 135 (7.7) 1 681 (7.5) 5 299 (7.0) Emergency department visits 0 188 264 (94.4) 204 141 (93.7) 158 508 (93.3) 24 992 (90.2) 20 314 (90.8) 68 559 (91.1) 1 8 318 (4.2) 10 105 (4.6) 8 267 (4.9) 1 914 (6.9) 1 517 (6.8) 4 798 (6.4) 2 1 847 (0.9) 2 325 (1.1) 1 975 (1.2) 471 (1.7) 330 (1.5) 1 175 (1.6) ≥ 3 1 105 (0.6) 1 384 (0.6) 1 103 (0.6) 317 (1.1) 209 (0.9) 743 (1.0) ≥ 1 11 270 (5.6) 13 814 (6.3) 11 345 (6.7) 2 702 (9.8) 2 056 (9.2) 6 716 (8.9) Note: HBA1c = glycated hemoglobin.
*Optimal monitoring defined as 1 retinal eye exam, 1 cholesterol test, and 4 HBA1c tests during the 2-year study period.
†Hospital visits for diabetes complications included visits for hyper/hypoglycemia, skin or soft-tissue infection, or cardiovascular events.
- Table 3: Association between primary care physician supply and optimal monitoring* (n = 610 441) and hospital visits for diabetes complications† (n = 712 681), by urban and nonurban networks
Outcome/model Urban Nonurban RR (95% CI) p value RR (95% CI) p value Optimal monitoring* Unadjusted High 1.06 (1.04-1.07) < 0.001 1.16 (1.13-1.20) < 0.001 Medium 1.03 (1.02-1.04) < 0.001 1.18 (1.14-1.23) < 0.001 Low (reference) 1.00 1.00 Adjusted for patient characteristics‡ High 1.06 (1.04-1.07) < 0.001 1.17 (1.14-1.21) < 0.001 Medium 1.04 (1.03-1.05) < 0.001 1.19 (1.14-1.23) < 0.001 Low (reference) 1.00 1.00 ≥ 1 emergency department visits Unadjusted High 1.11 (0.89-1.38) 0.4 0.96 (0.83-1.11) 0.6 Medium 1.10 (0.87-1.40) 0.4 0.94 (0.79-1.12) 0.5 Low (reference) 1.00 1.00 Adjusted for patient characteristics‡ High 1.05 (0.94-1.17) 0.4 0.96 (0.85-1.08) 0.5 Medium 0.99 (0.89-1.10) 0.9 0.95 (0.80-1.11) 0.5 Low (reference) 1.00 1.00 One or more hospital admissions Unadjusted High 1.04 (0.84-1.29) 0.70 0.93 (0.79-1.10) 0.4 Medium 1.08 (0.85-1.36) 0.5 0.97 (0.83-1.13) 0.7 Low (reference) 1.00 1.00 Adjusted for patient characteristics‡ High 1.01 (0.89-1.14) 0.9 0.91 (0.77-1.07) 0.2 Medium 0.97 (0.86-1.10) 0.6 1.09 (0.94-1.27) 0.2 Low (reference) 1.00 1.00 Note: CI = confidence Interval, RR = relative risk.
*Defined as 1 retinal eye exam, 1 cholesterol test and 4 glycated hemoglobin tests during the 2-year study period.
†Visits for hyperglycemia or hypoglycemia, skin or soft-tissue infection, or cardiovascular events.
‡Age, sex, income quintile, recent immigration, diabetes duration, mental health diagnosis, comorbidity and morbidity.
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