BARRIERS TO CARE IN NON-INSULIN-DEPENDENT DIABETES-MELLITUS - THE MICHIGAN EXPERIENCE

Objective: To determine the barriers to optimal care at the community level for patients with non-insulin-dependent diabetes mellitus (NIDDM ). Design: Comprehensive evaluation of the clinical, psychosocial, and educational status of community-based patients with NIDDM, with subse quent review by local diabetes advisory councils of this status and th e care those patients have received. The frequency with which patients visited their physician for diabetes management, received patient edu cation, received diet counseling, and were examined by an ophthalmolog ist-four services universally recognized to be components of optimal d iabetes care-was determined for all patients. Setting: Eight Michigan communities, four large and four small. Patients: From 1988 to 1994, 1 056 patients with NIDDM (defined by stimulated C-peptide criteria) wer e studied. Results: The frequency with which all patients with NIDDM v isited their community primary care physician in 1994 was 3.7 times pe r year (4.6 times for patients taking insulin and 3.2 times for those not taking insulin). Thirty-three percent of all patients with NIDDM ( 48% of those taking insulin and 24% of those not taking insulin) had r eceived all three other essential services, whereas 15% (6% taking ins ulin and 20% not taking insulin) had never received any of these servi ces. Factors contributing to this level of care and barriers preventin g more intensive management of community-based patients with NIDDM wer e identified by the diabetes advisory councils as they analyzed data f rom their own communities. The councils determined that the main barri ers to optimal care of community-based patients with NIDDM are that 1) NIDDM is not considered or managed as a serious problem by most physi cians and their patients; 2) the genetic basis for and refractory natu re of obesity are not generally appreciated; and 3) as a complex, mult isystemic chronic illness, diabetes fits poorly in a health care deliv ery system designed to deal with acute and episodic illnesses. Conclus ion: Most community-based patients with NIDDM are not aggressively man aged because of attitudinal, educational, and systemic factors that ac t as barriers to optimal health care delivery.