Diabetic Disparity: Rural/Urban Differences in Quality Outcomes within a Large Health System.

Context: Type 2 diabetes mellitus continues to grow as a national health priority that disproportionately affects rural patients. Objective: To compare patient level quality outcome data between rural and urban patients across a large integrated health system and assess healthcare utilization differences. Study design and Analysis: Retrospective cross-sectional study Setting or Dataset: Clinical data was collected those with type 2 diabetes across Mayo Clinic Family Medicine Midwest practice. Patient level data included address, age, sex, race, ACG score (marker of complexity), insurance status, primary care clinician, and utilization data. Population studied: Empaneled patients with an ICD-10 diagnosis of type 2 diabetes mellitus (45,279). Intervention/Instrument: Patients were divided into rural and urban cohorts based on RUCA codes then outcomes and utilization were analyzed using logistic regression and linear mixed models, with site and provider as random effects. Outcome measures: Patients meeting 5 criteria included in a composite quality metric for diabetes management (D5) Results: Rural patients were significantly less likely to have met all D5 criteria than urban patients (OR 0.93 (95% CI 0.88-0.97)). Utilization analysis shows that rural patients had fewer outpatient visits than their urban counterparts (mean visits 3.2 v 3.9, p<.0001) and fewer endocrinology visits (5.5% of patients v 9.3%, p<.0001). Medicaid patients were less likely to have met D5 compared to commercially insured patients (OR 0.58 (0.53-0.63)), whereas Medicare patients were more likely to have met D5 outcomes than commercially insured patients (1.17 (1.10-1.24)). Patients with non-white ethnicity were less likely to meet D5 (0.83 (0.77-0.90)), as were those with an endocrine visit during the study period (0.80 (0.73-0.86)). The number of outpatient visits was positively associated with D5 attainment (1.03 (1.03, 1.04)) as was female sex (1.08 (1.04, 1.12)), advancing age (1.02 (1.01, 1.02)) and lower ACG (1.19 (1.14, 1.25)). Provider type (NP/PA vs. physician) was unrelated to D5 outcome (0.94 (0.87, 1.02)). Conclusions: Rural patients had worse diabetic quality outcomes than their urban counterparts, even after adjustment for other contributing factors and despite being part of the same integrated health system. Increasing visit frequency may improve D5 outcomes in rural patients. [ABSTRACT FROM AUTHOR]