|Year : 2015 | Volume
| Issue : 1 | Page : 5-10
Healthcare Utilization Pattern of Patients with Diabetes in the Selected Medical Centers of the City of Isfahan, Iran
Mansoure Majlesi1, Manal Etemadi2, Elahe Khorasani3
1 Department of Master of Business Administration (MBA), School of Management, Hamedan Payame Noor University, Hamedan; Department of Healthcare Management, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Health Services, Management and Health Policy, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
3 Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran; Department of Healthcare Management, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||3-Jul-2015|
Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Keshavarz Boulevard, Tehran
Source of Support: None, Conflict of Interest: None
Introduction: Diabetes is the fourth leading cause of death in societies. Diabetes is not only considered just a disease but also is an interwoven network of environmental and genetic risk factors with different pathophysiology which is very costly. The aim of the present study is to investigate the utilization pattern of patients with diabetes in the centers of the City of Isfahan. Materials and Methods: The present study is a cross-sectional study which employs a descriptive method. In this study, the medical records of patients with diabetes referring to five diabetic care centers (a private center, a state-run center, a charity services center, a sub-specialized eye care center, and a subspecialized center for diabetic foot treatment) in the first half of 2013 were investigated. The data analysis was conducted using Microsoft Excel. Results: Most of the admitted patients were referred ones and the least of them were introduced by other centers. In the second level, visits to specialists and visits to ophthalmologists had the highest frequency. In the charity center, visits to internists had the highest frequency. In the state center, visits to ophthalmologists had the highest frequency. Conclusion: Regarding the favorability of the degree of diabetic patients' access to services in the City of Isfahan, policy making for public screening for identifying latent cases of diabetes and including patients in treatment cyclesin order for preventing the incidence of side effects and diabetes in the members of patients' families seem necessary.
Keywords: Diabetes, health care, healthcare services, levels of service delivery, services offer levels, taking benefits, utilization
|How to cite this article:|
Majlesi M, Etemadi M, Khorasani E. Healthcare Utilization Pattern of Patients with Diabetes in the Selected Medical Centers of the City of Isfahan, Iran. J Earth Environ Health Sci 2015;1:5-10
|How to cite this URL:|
Majlesi M, Etemadi M, Khorasani E. Healthcare Utilization Pattern of Patients with Diabetes in the Selected Medical Centers of the City of Isfahan, Iran. J Earth Environ Health Sci [serial online] 2015 [cited 2019 Dec 13];1:5-10. Available from: http://www.ijeehs.org/text.asp?2015/1/1/5/159920
| Introduction|| |
Diabetes refers to a set of disorders of carbohydrate, fat, and protein metabolism screated by the presence or the absence of insulin secretion or the reduction in the sensitivity of tissues to insulin.  Diabetes is the commonest disease due to metabolic disorders and the fourth leading cause of death in Western societies. The pathogenicity of this disease whether in terms of treatment costs or due to extremely high disability, is one of the major healthcare issues which have been considered more important due to the rise in urbanization and changes in lifestyles towards inactivity and poor nutrition.
Diabetes can have undesirable consequences for all patients' parts. World Health Organization has estimated that there are 24 million cases of diabetic neuropathy, 6 million cases of amputation, and 5 million cases of diabetic retinopathy. Cardiac problems (myocardial ischemia, heart attack, and peripheral vascular diseases) are reported as the main causes of mortality in patients with this disease. 
It has been estimated that the number of patients with diabetes increases from 171 million to 366 million cases in the time period from 2000 to 2030. In Iran, 1.5 million people suffer from this disease.  The prevalence rate of diabetes in adults in Iran has been estimated as 2-10%. Deputy for Health of Ministry of Health and Medical Education has reported the prevalence of diabetes 2.3% and Endocrine Research Center in Isfahan has reported this rate per the whole population as 2-3%, and in people over 30 years old as 7.3%. 
Diabetes is divided into two; early and secondary diabetes. Early diabetes includes type 1 diabetes, type 2 diabetes, and gestational diabetes. Secondary diabetes includes taking medications or can be observed with some diseases and in specific conditions such as surgery, acromegaly disease, Cushing's disease, and genetic disorders.
Among different types of diabetes, type 2 diabetes is the most prevalent.  One of the characteristics of this disease is insulin resistance in such a way that target tissues cannot appropriately use insulin.  The prevalence rate of type 2 disease is increasing in the world. Currently, it is estimated that the number of those with type 2 diabetes in the world is 285 million patients. By 2025, this number will increase to 330 million patients and by 2030 to 366 million cases.  According to the latest report of a systematic review study, in Iran the prevalence rate of type 2 diabetes for individuals above 40 years is estimated to be 24%. 
Diabetes is a costly disease in the healthcare system and in many countries, in ages from 20 to 70 years; it is the main cause of blindness, amputation, and kidney failure. Since its definitive treatment is elusive, by timely diagnosis and appropriate cares, the prevalence of its effects and consequences can be prevented significantly. 
Regarding the chronic, non communicable, and costly nature of this disease for public health, and its creation of great financial burden, it seems necessary that it should be seriously paid attention to.  Diabetes is not just a disease, but it is an interwoven network of environmental and genetic risk factors with different pathophysiology which is very costly and disabling because of features such as laying the foundations for and accompanying other diseases.
Long-term complications of diabetes include cardiovascular complications, diabetic retinopathy, nephropathy, and neuropathy; which occur in case of poor glycemic control in patients with diabetes and result in disability and high mortality rate, while by appropriate diagnosis, care, and control of the disease in its early stages, the incidence of its serious side effects, and in case of the incidence of side effects, disabilities due to it can be prevented.
In Iran's healthcare system, to manage types of patients, a model was defined by the Ministry of Health and services provided in three levels. The first level includes screening services and primary healthcare. These services are burdened on the health team (nurses, family medicines, and dietitians), and as the first level of prevention, it is under the supervision of the Health Deputy. This level is responsible for continuous patients' care. Via the health team, this level is burdened with the responsibilities of screening, caring, training, and supervising self-care measures of patients' self-care interventions, referring to diabetes specialized centers and then, receiving feedbacks of specialized cares and following up the treatment of patients with diabetes.
The second level includes specialized services provided in diabetes centers (in private/state hospital or private/state specialized clinics and polyclinics) under the supervision of the treatment deputy chancellors of the Universities of Medical Sciences. This level, enjoying specialized facilities for diagnosing, caring, and treating four major complications of diabetes including diabetic foot, diabetic retinopathy, cardiovascular problems, and diabetic nephropathy and neuropathy does its responsibilities in accordance with the first level of services. According to the instructions of national programs to prevent and control diabetes, the existence of internists and services of ophthalmology are considered as the minimum standards for specialized services at the second level. All diabetic patients under the care of a healthcare center should annually refer to the second level for the evaluation of chronic effects and visits to internists and ophthalmologists. Diabetics refer to the second level in some ways; they are referred to this level by the units of the first level, they refer directly to specialized clinics, they are introduced by other clinics and hospitals, and they refer to the emergency unit of hospitals due to acute complications of the disease. The third level includes subspecialized services delivered in private/state subspecialized hospitals, polyclinics and clinics, diabetes research centers, and endocrinology and metabolism research centers. The objective of the present study is to investigate the degree of diabetic patients' use of specialists' services in the mentioned centers in order to provide proper grounds for investigating factors affecting the model of taking benefits from diabetes services in different centers.
| Materials and Methods|| |
The present study is a cross-sectional one which employs a descriptive method. After obtaining permission from Isfahan University of Medical Sciences and its Treatment Deputy Chancellor, collecting data was started.
The studied population included the medical records of patients having referred to the care centers for diabetics, and to collect data, investigating the available documents and data registered about patients were used. In the present study, the patients' medical records in the first half of 2013 were investigated.
In the present study, a number of first-, second- and third-level centers were selected for conducting the research:
- A private polyclinic having first-level services (physicians trained in diabetes, nurses, and dietitians) and second-level services (internists and ophthalmologists).
- A private charity center including providing comprehensive first- and second-level services.
- A subspecialized diabetes center (third-level services) providing diabetic patients with ophthalmological services including optometry, eye angiography, fund us photography and laser therapy and surgery, and other subspecialized eye therapies. If needed, patients are referred to internists.
- A second- and third-level state center providing services related to internal medicine and glands with patients.
- A subspecialized center for the treatment of diabetic foot ulcers (third-level services). This center is for diabetic patients who exclusively refer to it for the treatment of diabetic foot ulcers, but if needed, patients are referred to other second-level services (internist, ophthalmologists, etc.).
To observe ethics, the collected data were kept confidential and anonymously analyzed. The data were analyzed using Microsoft Excel.
| Results|| |
[Table 1] indicates that, in general, most of the admitted patients were referred cases and the least of them were referred by other centers. Only in the state center, most of the visitors were the previous patients of the center.
|Table 1: Frequency distribution of the type of patient admissions divided by the selected clinics|
Click here to view
[Table 2] indicates that, in general, the most common cause of admitting referred patients was annual evaluation and the least common cause of admitting them was related to gestational diabetes. Only in the charity center and subspecialized center for diabetic foot treatment, the most common cause was follow-up treatment.
|Table 2: Frequency distribution of the causes for admitting referred patients as divided by the selected clinics|
Click here to view
[Table 3] indicates that, in general, in the second level which includes visits to specialists and visits to ophthalmologists had the highest frequency and visits to other specialists had the least frequency. In the charity center, visits to internists had the highest frequency. In the state center and the subspecialized ophthalmology center, visits to ophthalmologists had the highest frequency, and in the subspecialized treatment of diabetic foot center, the highest frequency was related to visits to subspecialists.
|Table 3: Frequency distribution of specialized and subspecialized examination and cares divided by the selected clinics|
Click here to view
[Table 4] indicates that in general, peripheral diseases care in diabetic patients in order of frequency iscardiovascular disease, retinopathy, neuropathy, and chronic renal disease. In cardiovascular care, blood pressure control had a more proportion than electrocardiogram (ECG). In neuropathy care, autonomic neuropathy had more proportion than the monofilament test or tuning fork test. Only in the subspecialized ophthalmology center, compared to other centers, the most common provided service was related to retinopathy and after that, to autonomic neuropathy.
|Table 4: Frequency distribution of peripheral diseases care in patients divided by the selected clinics|
Click here to view
The results of [Table 5] indicate that, in general, the frequency of diagnostic measures were related to biochemical tests, fund us photography, ECG, chest X-ray, kidneys and urinary tract sonography, angiography, echocardiography, exercise testing, and renal biopsy. The highest degree of provided diagnostic services was in the subspecialized ophthalmology center in which fundus photography had the highest frequency. But the degree of biochemical test was zero. In the charity center, ECG had the most proportion of services. In the private center and subspecialized centers, biochemical tests had the highest frequency.
|Table 5: Frequency distribution of diagnostic measures in patients divided by the selected clinics|
Click here to view
[Table 6] indicates that, in general, diagnostic measures in order of frequency are related to biochemical tests, fund us photography, ECG, chest X-ray, kidneys and urinary tract sonography, angiography, echocardiography, exercise testing, and renal biopsy. The highest degree of provided diagnostic services was in the subspecialized ophthalmology center in which fundus photography had the highest frequency, but the degree of biochemical tests was zero. In the charity center, ECG had the highest proportion of services. In the private center and subspecialized centers, chemical tests had the highest frequency.
Laser therapy is the least common cause of admission. Laser therapy was provided only in the private center and the subspecialized ophthalmology center. In general, hospitalization was the most common cause of patient admission which in the order of frequency, it was observed in the subspecialized ophthalmology center, the state center, and the subspecialized treatment of diabetic foot. Laser therapy is the least common cause of patient admission.
|Table 6: Frequency distribution of the cause of admission divided by the selected clinics|
Click here to view
| Discussion|| |
The data related to the use of healthcare services in the diabetic patients in Isfahan during the first half of 2013 indicate that from the patients referred to the selected clinics, the least common cause of admission in the referred patients was related to gestational diabetes (0%). Its reason can be referred to age group, gender, socioeconomic status, the type of dispersion, and distribution of the diabetic population; referring patients to clinics or women's specialized and subspecialized endocrinology centers for gestational diabetes control and treatment because studies indicate that in Iran, on an average in different provinces, the prevalence rate of gestational diabetes is at a high level. 
In terms of receiving specialized and subspecialized care, in the present study, visits to ophthalmologists had the highest frequency and visits to other specialists had the least frequency. According to the report of the Agency for Healthcare and Quality Research, the commonest visits were to ophthalmologists, and in the next rank, the commonest visits were to optometrists and heart specialists.  In his study, El Fakiri indicated that the most common visit of patients with type 1 diabetes was to internists and in type 2 diabetes it was to ophthalmologists.  In general, all similar studies indicate that most common diabetic patients' visit was to ophthalmologists.
Regarding receiving peripheral diseases care in the present study, it was related to the following cares in the order of frequency: Cardiovascular disease, retinopathy, neuropathy, and chronic kidney disease. According to the report of the Agency for Healthcare and Quality Research, the treatment of rheumatoid arthritis, chronic obstructive pulmonary disease, depression, and Alzheimer were the most common peripheral diseases.  Tomlin indicated that ischemic heart disease, heart failure, and cataract were the most common peripheral cares in diabetic patients in New Zealand.  Al-Adsani and Abdulla in their research introduced five peripheral cares of Kuwaiti diabetic patients as acute coronary syndrome, pneumonia, heart failure, stroke, and chronic obstructive airways disease.  In general, it can be concluded that the care model of peripheral diseases in diabetic patients are mostly related to heart, lung, brain, and nerves diseases.
Hospitalization was the most common cause of patient admission in hospitals (95%) during the first 6 months of 2013. This result is at a higher level than that of Harris (26%) during 1year.  In case of patients with diabetes in Spain, the hospitalization rate increased from 13.2% in 1993 to 18% in 2006.  Tomlin reported the annual hospitalization rate of diabetic patients as 22%.  On the other hand, the significant difference of hospitalization rate in state educational hospitals with that in private and charity centers indicates that the degree of the use of these services by diabetic patients in state hospitals is more due to their lower costs. Chaikledkaew et al., in their research, confirmed this result. 
In general, the level of the access of diabetic patients to healthcare services is at a favorable level in the present study, screening patients in terms of peripheral diseases is conducted favorably, and diabetic patients' health status is favorable in terms of peripheral diseases and hospitalization rate is high. Harris, in his study, indicated that the level of access to services is favorable in Maryland State, but patients' health status is at an unfavorable level.  Regarding the favorability of the degree of diabetic patients' access to services in Isfahan, it is suggested that some appropriate policies should be made for conducting public screening in order to identify final cases of diabetes and entering patients in the treatment cycle for preventing the incidence of side effects in the patients and also the incidence of diabetes in members of patients' families. In this line, paying attention to diabetic patients' promoting health literacy  is very important. In fact, it can have a significant role in controlling the disease. 
| Acknowledgment|| |
The researchers are grateful for the sincere cooperation of the Treatment Deputy Chancellor of Isfahan University of Medical Sciences.
| References|| |
Meraci M, Feizi A, Nejad MB. Investigating the prevalence of high blood pressure, type 2 diabetes mellitus and related risk factors according to a large general study in Isfahan-using multivariate logistic regression model. J Health Syst Res 2012;8:193-203.
Tol A, Tavassoli E, Sharifirad G, Shojaezadeh D, Azadbakht L. The relationship between socioeconomic factors and their effects on patients with type 2 diabetes. J Health Syst Res 2011;7:138-47.
Pouya F, Larijani B, Pajouhi M, Lotfi J, Nurai M, Bandarian F. Peripheral Neuropathy in Diabetic Patients and Its Contributing Factors. Iranian Journal of Diabetes and Metabolism. 2004;3:41-6.
Ahmad Kiadaliri A, Najafi B. Obesity in type 2 diabetes: A review of health economics evidences. Hakim Res J 2012;14:233-41.
Hosseini R, Davoudabadifarahani A. Diabeticretinopathy and its risk factors in diabetic patients referred to diabetes clinic, training center - the city of Qom Kamkar Hospital. Qom Univ Med Sci 2012;5:40-6.
Amini M, Mehrmohammadi N, Aminroaya A. Prevalence of type 2 diabetes in asymptomatic women 25 to 70 years who were referred to Isfahan endocrine and metabolism research center. ZUMS J 2004;12:33-40.
Tol A, Sharifirad G, Eslami A, Alhani F, Tehrani M, Shojaezadeh D. Self-efficacy: An efficient functional concept in type 2 diabetes control. J Health Syst Res 2012;8:339-47.
Shahbazian H, Shahbazian N, Yarahmadi M, Saiedi S. Prevalence of gestational diabetes mellitus in pregnant women referring to gynecology and obstetrics clinics. Med Sci J Ahvaz Jondi Shapoor 2012;11:113-21.
Virnig BA, Shippee ND, O›Donnell B, Zeglin J, Parashuram S. Use of and access to health care by Medicare beneficiaries with diabetes: Impact of diabetes type and insulin use, 2007-2011: Data Points # 18.
El Fakiri F, Foets M, Rijken M. Health care use by diabetic patients in the Netherlands: Patterns and predicting factors. Diabetes Res Clin Pract 2003;61:199-209.
Tomlin AM, Tilyard MW, Dovey SM, Dawson AG. Hospital admissions in diabetic and non-diabetic patients: A case-control study. Diabetes Res Clin Pract 2006;73:260-7.
Al-Adsani A, Abdulla KA. Reasons for hospitalizations in adults with diabetes in Kuwait. Int J Diabetes Mellit 2011.
Harris MI. Health care and health status and outcomes for patients with type 2 diabetes. Diabetes Care 2000;23:754-8.
Lopez-de-Andres A, Hernández-Barrera V, Carrasco-Garrido P, Gil-de-Miguel Á, Jiménez-García R. Use of health care services among diabetic Spanish adults: Related factors and trends, 1993-2006. J Diabetes Complications 2010;24:96-101.
Chaikledkaew U, Pongchareonsuk P, Chaiyakunapruk N, Ongphiphadhanakul B. Factors affecting health-care costs and hospitalizations among diabetic patients in Thai public hospitals. Value Health 2008;11:S69-74.
Karimi S, Keyvanara M, Hosseini M, Jazi MJ, Khorasani E. The relationship between health literacy with health status and healthcare utilization in 18-64 years old people in Isfahan. J Educ Health Promot 2014;3:75.
Jabbari A, Khorasani E, Jazi MJ, Mofid M, Mardani R. The share of adverse events from patients› complaints: A case study. Int J Health Syst Disaster Manag 2014;2:34-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]