To my family who has never doubted my ability to succeedufdcimages.uflib.ufl.edu/UF/E0/05/12/13/00001/TAYLOR_S.pdf · to refer or not to refer: an evaluation of provider perceptions

TO REFER OR NOT TO REFER: AN EVALUATION OF PROVIDER PERCEPTIONS OF

BARRIERS TO DIABETES SELF-MANAGEMENT PROGRAMS

By

SHANNON TAYLOR

A THESIS PRESENTED TO THE GRADUATE SCHOOL

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2017

© 2017 Shannon Taylor

To my family who has never doubted my ability to succeed

4

ACKNOWLEDGMENTS

I would like to first acknowledge and thank my graduate committee for their constant

support and feedback, specifically Dr. Ashby Walker and Dr. Bruce Vogel. Without their

guidance, this project would not have come to a successful fruition. I’m grateful for their

mentorship and advice which will have a lasting effect throughout the entirety of my career.

Additionally, I would like to acknowledge my peers, specifically Alana Klonoski, who never

ceased to provide ample motivation throughout the completion of this project. Finally, I would

like to acknowledge my family who has continued to believe in my abilities as a student to

succeed academically no matter the encountered obstacles.

5

TABLE OF CONTENTS

page

ACKNOWLEDGMENTS ...............................................................................................................4

LIST OF TABLES ...........................................................................................................................7

LIST OF FIGURES .........................................................................................................................8

ABSTRACT .....................................................................................................................................9

CHAPTER

1 INTRODUCTION ..................................................................................................................11

Purpose of the Study ...............................................................................................................11

Significance of the Study ........................................................................................................12 Theoretical Framework ...........................................................................................................12

Research Questions .................................................................................................................12

2 LITERATURE REVIEW .......................................................................................................13

Review of Diabetes Mellitus ..................................................................................................13

Treatment Options for Type 2 Diabetes .................................................................................13 The Health Benefits of DSME: Lowering HbA1c .................................................................14

The Health Benefits of DSME: Weight Loss .........................................................................15

The Health Benefits of DSME: Psychological Support .........................................................15

The Health Benefits of DSME: Decrease in Medical Cost ....................................................16 Underutilization of DSME ......................................................................................................17

Summary .................................................................................................................................18

3 CONCEPTUAL FRAMEWORK ...........................................................................................19

The Gatekeeper Theory ..........................................................................................................19 Theoretical Model ...................................................................................................................20

Dependent Variable one (DV1): Knowledge of the program as a barrier ......................20 Dependent Variable two (DV2): Referral Behavior .......................................................21 Independent Variables one and two (IV1, IV2): Provider demographics ......................21

Independent Variable three and four (IV3, IV4): Provider’s patient load ......................22

Independent Variables five and six (IV5, IV6): Influential factors to refer ...................22

Research Objectives ................................................................................................................23 Summary .................................................................................................................................24

4 METHODOLOGY .................................................................................................................25

Setting .....................................................................................................................................25 Participants .............................................................................................................................25

6

Research Design .....................................................................................................................26

Survey Instrument ...................................................................................................................26 Statistical Analysis ..................................................................................................................29 Summary .................................................................................................................................32

5 RESULTS ...............................................................................................................................34

Sample ....................................................................................................................................34 Data Consolidation .................................................................................................................36 Descriptive Frequencies Concerning the Research Questions ...............................................37 Linear Probability Models ......................................................................................................39

Qualitative Coding Analysis ...................................................................................................43 Summary .................................................................................................................................44

6 DISCUSSION .........................................................................................................................46

Research Questions .................................................................................................................46 Conclusions.............................................................................................................................48 Limitations ..............................................................................................................................50

Future Research ......................................................................................................................51

APPENDIX

A INFORMED CONSENT ........................................................................................................52

B SUVEY SAMPLE ..................................................................................................................53

LIST OF REFERENCES ...............................................................................................................59

BIOGRAPHICAL SKETCH .........................................................................................................65

7

LIST OF TABLES

Table page

4-1 Variables of Interest Location in Survey ...........................................................................28

5-1 Frequency of Responses by Specialty................................................................................35

5-2 Physician Demographics ....................................................................................................35

5-3 Dichotomized Variables.....................................................................................................37

5-4 Chi Square Results for Knowledge as a Barrier (DV1) .....................................................38

5-5 Chi Square Results for Referral Behavior (DV2) ..............................................................39

5-6 Preliminary Linear Probability Model for Knowledge as a Barrier (DV1) .......................40

5-7 Final Linear Probability Model for Knowledge as a Barrier (DV1) ..................................41

5-8 Preliminary Linear Probability Model Results for Referral Behavior (DV2) ...................42

5-9 Linear Probability Model for Referral Behavior ...............................................................43

8

LIST OF FIGURES

Figure page

3-1 Theoretical Model ..............................................................................................................20

4-1 Thematic Coding Process ..................................................................................................32

5-1 Coded Responses ...............................................................................................................44

9

Abstract of Thesis Presented to the Graduate School

of the University of Florida in Partial Fulfillment of the

Requirements for the Degree of Master of Science

TO REFER OR NOT TO REFER: AN EVALUATION OF PROVIDER PERCEPTIONS OF

BARRIERS TO DIABETES SELF-MANAGEMENT PROGRAMS

By

Shannon Taylor

May 2017

Chair: Bruce Vogel

Cochair: Ashby Walker

Major: Medical Sciences

Although the prevalence of diabetes is increasing and education remains a cornerstone to

long-term management, attendance to diabetes self-management education programs (DSME)

remains underutilized. While numerous studies examine underutilization of DSME from the

patient’s perspective, there is a lack of research focused on factors related to the provider’s

decision to refer to these programs. To gain a better understanding of the physician’s role as

gatekeeper to DSME, this study surveyed 44 physicians in an academic medical center to

evaluate whether their knowledge about DSME serves as a barrier to referral, influences their

referral behavior, as well as identify provider feedback regarding perceived issues surrounding

DSME. A 56 item survey was administered through REDCap® to generalists and specialists.

Both descriptive and multivariable statistical analyses were performed to identify significant

factors that influenced provider referral behavior to DSME through both direct and indirect

relationships.

The indirect pathway was based on whether physicians viewed lack of knowledge about

DSME as a barrier to refer. It was found that generalists (29.5 %), physicians with longer lengths

of practice (52 %), and with a larger percent of patients with diabetes (34.8 %) have a lower

10

probability of reporting this behavior. The direct probability of a physician referring a patient to

DSME was increased by 40 % for physicians who have longer lengths of practice but decreased

by 32 % and 56 % for physicians who provide diabetes education to patients and who found the

referral process difficult, respectively. In sum, physicians are more likely to be effective

gatekeepers are those with longer practice lengths, higher percent of patients with diabetes,

provide their own diabetes education to patients, find the referral process easy, and are

generalists. Additionally, patient motivation and access to transportation were reported as the

biggest barriers for underutilization of DSME (19 % and 30.1 %, respectively). These findings

emphasize the need for DSME promotion specific to newly practicing physicians in an internal

subspecialty. An intervention should be created that informs this target physician group about the

benefits of DSME, how to refer patients, and ways to motivate patients to attend these programs.

11

CHAPTER 1

INTRODUCTION

Among the many chronic diseases, diabetes mellitus (DM) ranked as the 7th leading cause

of death for Americans in 2014.1 It is a disease that currently affects 29.1 million Americans and

continues to grow at a rate of 1.4 million people per year. 2 Between 2005 to 2050, its prevalence

is projected to increase by 198%, an estimated 48.3 million people.3 The American Diabetes

Association (ADA) reports that diabetes and prediabetes are associated with 322 billion dollars

in medical costs per year4. Of that total, 43% stems from hospital inpatient care and 18% from

prescription medication needed to treat diabetes related complications.5

Of the three types of diabetes mellitus, type 2 diabetes accounts for 90-95% of diagnosed

cases in the United States.6 A person is diagnosed with this disease based on elevated blood

glucose levels. If left untreated, a patient can develop more severe complications including

impaired vision, kidney function, and can eventually lead to a foot amputation.7 Understanding

the disease and monitoring its symptoms are crucial for newly diagnosed patients, but many do

not participate in Diabetes Self-Management Education (DSME) programs.8 DSME teaches

patients to manage their disease by monitoring glucose levels and improving lifestyle habits.9

When patients are diagnosed with diabetes, physicians can refer them to DSME. Multiple

research studies have demonstrated the positive impact of DSME on a patient’s health and

quality of life.10 Despite its record of success, DSME is an underutilized resource and one

possible cause is the lack of patient referrals.11–14

Purpose of the Study

The purpose of this study is to examine multiple physician-related factors and their

influence on a physician’s decision to refer patients with diabetes to DSME and ultimately their

role as gatekeepers.

12

Significance of the Study

Low patient attendance in DSME is a highly investigated topic, but there is little research

that focusses on physicians and their behavior. Understanding the factors that impact the referral

decision will help diabetes educators develop interventions for physicians with these factors with

the intention of increasing referral rates.

Theoretical Framework

In healthcare, a gatekeeper is defined as a medical professional who has the first

encounter with a patient and thus determines the next level of treatment.15 When treating DM,

physicians are the gatekeepers to DSME. Measuring a physician’s view of program knowledge

as a barrier and their referral behavior will provide insight in regards to a physician’s role as

gatekeeper.11,16–19 The literature identifies six variables that may influence a physician’s

knowledge of DSME and referral behavior. They include a physician’s specialty, length of time

in practice, number of patients with diabetes, number of patients with uncontrolled diabetes,

whether a physician provides diabetes education, and the ease of the referral process.12,19–21

Research Questions

In order to determine the physician’s role as gatekeeper and their perceived barriers to

refer patients to DSME, this study investigates three questions: 1) how does physicians’ view of

program knowledge as a barrier vary with length of time in practice, specialty, number of

patients with diabetes, and number of patients with uncontrolled diabetes, 2) how is physicians’

perceptions of their propensity to refer their patients to DSME related to their length of time in

practice, specialty, number of patients with diabetes, number of patients with uncontrolled

diabetes, perception of program knowledge as a barrier, ease of referral to diabetes education,

and physician-provided of diabetes education, and 3) what information do physicians have from

their patients that can help diabetes educators improve DSME programs?

13

CHAPTER 2

LITERATURE REVIEW

This chapter provides substantial background information about the different types of

diabetes mellitus, their etiologies, and symptoms. An introduction to treatment options,

specifically DSME, is included followed by a detailed account of the benefits that occur after

attending such educational programs. Finally, reasons for patient underutilization of DSME are

outlined and discussed.

Review of Diabetes Mellitus

There are three types of DM: type 1, type 2, and gestational diabetes. Type 2 diabetes is

(T2D) a disease where the body becomes resistant to insulin, the peptide hormone responsible

for the uptake of blood glucose. This resistance stems from a patient’s consistently high

consumption of carbohydrates and results in high blood glucose levels above 100mg/dL.22

Frequent urination, excessive thirst, slow ability to heal wounds, and blurry vision are a few of

the direct symptoms people with diabetes experience.7 If left untreated, severe complications

such as neuropathy, retinopathy, kidney disease, foot amputations, or diabetic ketoacidosis may

arise.23 Although there is no direct cure, individuals with T2D can minimize negative outcomes

by maintaining optimal glycemic control (blood glucose <100 mg/dL) and proactively managing

their disease.24

Treatment Options for Type 2 Diabetes

Treating T2D can include a number of behavioral interventions such as controlling

carbohydrate intake, engaging in regular physical activity, oral medication, insulin therapy, and

bariatric surgery.25 One far less invasive treatment option is DSME, an “ongoing process of

facilitating the knowledge, skill, and ability necessary for diabetes self-care” to improve clinical

outcomes, health status, and quality of life.9 Patients learn about DSME and gain access through

14

physician referral. Once referred, a patient diagnosed with diabetes can expect to meet with a

diabetes educator for several visits in either a group or 1 on 1 setting depending on the patient’s

insurance and finances.14 A majority of insurance plans allow up to 10 hours of education within

the first year after the initial referral date. Discussing the etiology of diabetes, mapping the steps

to manage the disease, and developing strategies to lead a healthier lifestyle are the focus points

of each meeting. However, DSME is currently an underutilized resource.14 Among the newly

diagnosed type 2 diabetes patients with private insurance, only 6.8% received DSME within 12

months of diagnosis and 5% received DSME for those with Medicare.26,27 Although many

patients do not attend DSME once referred, multiple studies have demonstrated the beneficial

impact DSME has for patients with type 2 diabetes.10

The Health Benefits of DSME: Lowering HbA1c

DSME is effective and one of its primary benefits includes lowering Hemoglobin A1c

(HbA1c), a biomarker referring to glycated hemoglobin.24 By checking this marker, providers

are able to determine the average blood sugar levels over a three-month period. HbA1c indicates

whether a person has uncontrolled (HbA1c > 8%) or controlled diabetes (HbA1c < 8%).28,29 A

meta-analysis was conducted to evaluate the effectiveness of DSME to lowering HbA1c. Across

118 interventions, there was a 0.74 and 0.17 mean reduction in A1c respectively between the

intervention group that attended a diabetes self-management program and the control group that

did not. In studies included patients with consistently higher A1c (>9), 83.9% had a statistically

significant reduction in A1c.30 Prior to this study, a fixed effect meta-analysis was conducted

studying the effects of educational programs on glycemic control. The average results between

the selected 28 interventions (n=2439) indicated an average net glycemic reduction of 32% in

diabetic patients.10 These studies highlight the positive benefits of attending DSME programs by

ultimately lowering the risk of developing diabetes related microvascular complications. The

15

Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study

(UKPDS) both indicated that a 1.1% reduction in A1c for individuals with either type 1 or type 2

would decrease the risk of developing microvascular complications by 25%.28,31,32

The Health Benefits of DSME: Weight Loss

Obesity is a concurrent disease for those diagnosed with type 2 diabetes; therefore, efforts

to reduce weight and weight gain not only improves a patient’s diabetes but decreases their risk

of developing cardiovascular disease. DSME has been proven to both counteract and neutralize

weight gain for patients who attend these sessions.33 The Look AHEAD trial found that after 1

year of intensive lifestyle intervention (ILI), participants lost an average of 8.6% of weight.34

The Look AHEAD study team also conducted an eight year study that witnessed a 5-10%

reduction in initial body weight for the majority of participants with type 2 diabetes in both their

intensive lifestyle and diabetes education study groups. These results showcase the positive

effects that stem from behavioral and educational interventions.35 Despite proven effectiveness,

adherence to intensive counseling for long periods is difficult for most patients. A study by the

Palo Alto Medical Foundation Research Institute gathered a large cohort of newly diagnosed

type 2 diabetics and found that after a three year follow up period (an extensive follow up time),

6.3lbs were lost after a 12-month counseling program and when medication was added, there was

an average reduction of 8.1 lbs. Based on these findings, researchers concluded that clinicians

should offer DSME to patients because even small amounts of education promotes weight loss

and risk reduction.36

The Health Benefits of DSME: Psychological Support

In addition to physical health, managing diabetes can negatively affect mental health.

Person’s with diabetes are twice as likely to develop co-morbid depression than those without the

disease.37–40 Of 5,104 participants in the Diabetes, Attitudes, Wishes, and Needs (DAWN) study,

16

41% reported poor psychological well-being. Among 8,596 participants in the DAWN2 study,

44.6% reported suffering from diabetes-related distress (DD), and only 48.8% had ever attended

a diabetes education program.41 These results show the high concurrent prevalence of

psychological issues among those with diabetes; however, participation in self-management

programs leads to positive mental changes in patients. Depression, anxiety, self-esteem, diabetes-

specific knowledge, and self-efficacy were crucial measures in an intervention trial that

integrated coping skills training with a diabetes education program. After the initial intervention,

rates of each variable significantly decreased and were maintained at the one year follow up.42 A

more recent study was conducted to determine the psychological outcomes across three different

educational and self-management interventions. Overall, 33% of the type 2 diabetics with high

DD and 60% of those with moderate DD claimed they no longer had these symptoms after a 12

month follow up, specifically those who participated in an enhanced self-management

curriculum.43 Multiple recent studies confirm these findings and provide more evidence

supporting DSME’s ability to diminish the psychological effects related to diabetes.44–46

The Health Benefits of DSME: Decrease in Medical Cost

DSME also leads to reduced health care costs. It is estimated that a person diagnosed

with diabetes spends on average $13,700.00 annually for medical expenses; an amount

approximately 2.3 times higher than for those without this chronic disease.5 Hospital visits,

medications to treat complications, and physician visits contribute to these high expenditures;

however, DSME lowers these costs and increase savings. A retrospective analysis was conducted

from data consisting of 7,000 people with diabetes taking part in Diabetes Treatment Centers of

America’s Diabetes NetCare, a comprehensive diabetes management program. They experienced

a gross economic adjusted savings of $50.00 per diabetic member per month (12.3%) and

hospital admissions per 1,000 diabetic members decreased by 18%.47

17

In 2010, diabetes mellitus with complications was ranked as the 17th leading cause of

readmission to a hospital with 20.3% of those admitted returning in within 30 days of release.48

Healy et. al studied the relationship between inpatient diabetes education (IDE) and hospital

readmission for uncontrolled diabetes and found that formal IDE was independently associated

with lower frequency of hospital readmission within 30 days.49 Duncan et. al analyzed

commercial and Medicare claims datasets to determine whether people with diabetes involved in

diabetes education were more likely to follow recommended methods of care. Their findings

indicated that collaboration between diabetes educators and providers have positive clinical and

cost outcomes; however, further improvements and cost reductions would stem from an increase

in physician referral rates to these programs. Importantly, the researchers advocate that more

physicians need to be informed in order to increase patient access to diabetes education.50

Underutilization of DSME

Although participating in DSME is highly beneficial, low patient attendance is an issue.

Studies investigating attendance have discovered several themes. The low referral rate to DSME

is a central cause another is the patient’s lack of perceived benefits from participating in

educational programs.8,51–54 Winkley et al. conducted a qualitative study where patients

expressed this sentiment and concluded that health care professionals should learn how DSME

programs help patients manage their disease. The patients felt that if their physician

communicated the importance of DSME and the seriousness of controlling their disease, the

patients would have attend the program.54 A study by Schewennessen et al. cited the lack of

perceived benefits as a detriment to DSME attendance and also noted that the timing of the

referral was another crucial theme. Among 15 patients with diabetes, interviews indicated that 6

would have participated in DSME if they were referred closer to the time of the initial

diagnosis.52 The theme of referral timing as well as lack of seriousness translated by physicians

18

were issues further discussed in a study done by Bedwell.8 Physician’s awareness and

recommendation of DSME are clear indicators of patient’s likelihood to attend and adhere to

these programs.51

Summary

Chapter 2 introduced DM, the role of diabetes education in self-management, and four

patient benefits: lowering HbA1c, encouraging weight loss, providing psychological support, and

decreasing medical costs. T2D is one of the most prevalent diseases associated with high

mortality rates, worsening complications and substantial medical costs in the nation. DSME

teaches patients to manage their symptoms and prevent the occurrence of complications using

lifestyle counseling. Programs demonstrate the ability to lower HbA1c levels, teach weight loss

strategies, provide psychological support, and reduce medical costs. Despite the growing

prevalence of diabetes and the numerous benefits of DSME, programs remain underutilized.

Several contributing themes have emerged to explain low referral rates and include: physician

lack of patient communication about DSME benefits, translated seriousness of T2D, and

improper timing of referral.

19

CHAPTER 3

CONCEPTUAL FRAMEWORK

Accepting that DSME can positively impact the health of patients with DM, this chapter

explains the conceptual context behind the problem of patient underutilization and highlights an

under researched cause to this issue. Physicians are gatekeepers who control patient access to

medical resources such as DSME. Therefore, analyzing a physician’s involvement in patient

adherence to DSME could help us understand low attendance rates. Variables that may impact a

physician’s decision to refer will be the focus of the study and their inter-relationships will be

discussed.

The Gatekeeper Theory

The term gatekeeper was first introduced in 1947 by Kurt Lewin, a historical social

psychologist, to address change in social communities;55 however, over time the term’s

definition and usage have changed and been applied to a variety of fields. In health care, a

gatekeeper is a medical professional who has the first encounter with a patient and thus

determines the next level of treatment.15 Most often the gatekeeper is a primary care physician

who monitors the secondary health pathway of a patient, but with regard to DSME, both

generalists and specialists may serve in this capacity. Each speciality is a direct line of access for

these patients to become informed and referred to DSME. Physician gatekeeping theory was

defined by Frank et al. as the process of matching patients’ needs and preferences to the

judicious use of medical services.56 This theory illustrates one of the foremost responsibilities a

physician has to direct patients so appropriate health resources.56,57It should be the goal of

generalists and specialists to prevent the exacerbation of each patient’s disease. For people with

diabetes this means decreasing HbA1c levels, avoid diabetic ketoacidosis, and lessen co-

20

morbidities. Referral to DSME is a crucial first step that all physicians should adhere to as well

as advocate their patients to utilize.

Theoretical Model

The goal of this study is to understand how physician’s perceived knowledge about

DSME and referral behavior are influenced directly and indirectly by different factors.

Measuring the relationships among these variables will identify aspects of the provider’s role as

gatekeeper to diabetes education. Figure 3-1 depicts the focus of this study’s quantitative aims

and illustrates the interactions to be analyzed. The following paragraphs define each variable and

explains why it is included in the model to predict physician referral behavior.

Figure 3-1. Theoretical Model

Dependent Variable one (DV1): Knowledge of the program as a barrier

This variable measures whether a physician’s perceived knowledge about the existence

and content of diabetes education programs is a barrier to referral. Earlier studies have focused

on physician knowledge of the disease and its effect on patient outcomes.16–18 Although

21

physician’s knowledge of DSME has been cited as a source of patient underutilization, there is

little information from the physician’s perspective regarding their knowledge of DSME and how

it impacts decisions to refer.19

Dependent Variable two (DV2): Referral Behavior

Research demonstrates the efficacy of DSME as a treatment option. In Brown et al.

general practitioners describe DSME as a valuable resource and recommend that patient referral

soon after diagnosis.19 Despite the evidence, the referral rate for DSME lags behind the rate of

diagnosed patients with diabetes. Ruppert et al. observed this trend and found that patients with

higher number of risk factors and co-morbid conditions received a referral as opposed to those

newly diagnosed.11 This variable will measure whether a physician refers their patients based on

self-report.

Independent Variables one and two (IV1, IV2): Provider demographics

A provider’s behavior may be influenced by demographic factors. The variables of

interest are length of time in practice (IV1) and specialty (IV2). A physician’s length of time in

practice is not a highly researched topic today but has shown mixed results regarding its effect on

referral behavior in past studies. In 2002, Chan et al. determined that physician’s age had no

effect on referral rates, but Cowen et al. in 1999 found the likelihood to refer was associated with

both age and years out of medical school.58,59 These findings suggest that physician’s length of

time in practice may influence a provider’s knowledge and referral behavior to DSME due to

varying experiences and amount of training received. A majority of studies regarding diabetes

and diabetes education referrals focus on the role of primary care physicians; however, many

patients with diabetes, especially those with more severe cases, are referred to specialists such as

endocrinologists. These patients then fall under the care of a specialist who has the opportunity

to refer patients to DSME. Katon et al. discussed the roles of specialists, primary care, and other

22

health practitioners and the positive effects that would stem from a more coordinated effort

between these groups of providers for patients with chronic illnesses.20

Independent Variable three and four (IV3, IV4): Provider’s patient load

A provider’s number of patients with diabetes (IV3) and number of patients with

uncontrolled diabetes (IV4) contributes to a patient’s adherence to recommended treatments.21

As mentioned in Ruppert et al., there is an apparent difference in the number of referrals

administered by physicians based on the severity of a patient’s condition. The findings were

calculated based on T2D patient information located in an online diabetes management system

and suggest that higher risk patients, those with a larger number of risk factors and comorbid

conditions, were more likely to receive a referral.11

Independent Variables five and six (IV5, IV6): Influential factors to refer

Physicians understand the importance of diabetes education and some provide such

education to patients during their visit rather than refer patients to DSME.13 One example of

educational materials In contrast, Brown et al. found that physicians reported having little time

and compensation when administering their own education to patients.19 In a study by Peyrot et

al., physicians did not agree with some of the treatments discussed by diabetes educators and

feared losing their patients after referring patients to DSME.12 Physician’s lack of time to

administer education and support in DSME supports the decision to ask physicians whether they

provide their own education (IV5) and interpret its effect on referral behavior. Diabetes

educators reported that ease of the referral process (IV6) is a determinant as to whether a

physician will refer a patient to DSME. Gucciardi et al. found physicians were less inclined to

refer due to patient characteristics as well as system and operational difficulties such as a long

referral process.13

23

Research Objectives

Most research focuses on patient and system level barriers to DSME. For patients, it has

been shown that a lack of educational program awareness, program misperceptions, structural

hindrances, and health beliefs are a few of the reasons preventing patients from attending

DSME.11,12,60–63 However, researchers stress a need for more physician referrals to DSME

programs and promotion of patient participation.11–13 Although lack of provider involvement is a

reported issue, there exists a gap in the literature regarding this crucial aspect of DSME from the

perspective of the physician.8

With the increase in hospitalized patients with uncontrolled diabetes and increasing

prevalence of the disease, the physician’s role as gatekeeper to DSME is a topic of increasing

importance. Provider attitudes and beliefs may influence the likelihood a patient adheres to self-

management treatment, yet there is little research about how provider and patient characteristics

influence referral patterns to DSME. 64 Therefore, this study will evaluate the relationships that

impact both generalists and specialists’ roles as gatekeepers to DSME using an online survey.

The research questions and associated hypothesis follow.

Research Question one (RQ1): How does physicians’ self-reported knowledge of

diabetes education as a barrier to referral and does it vary with length of time in practice,

specialty, number of patients with diabetes, and number of patients with uncontrolled

diabetes?

o Null Hypothesis one (H01): Physicians’ perceived knowledge of diabetes

education as a barrier to referral is not significantly related to either physicians’

length of time in practice, specialty, number of patients with diabetes, and/or

number of patients with uncontrolled diabetes.

o Alternative Hypothesis one (Ha1): Physicians’ perceived knowledge of diabetes

education as a barrier to referral is significantly related to either physician’s

length of time in practice, specialty, number of patients with diabetes, and/or


Research Question two (RQ2): How are physicians’ report of their propensity to refer

patients to DSME relate to length of time in practice, specialty, number of patients with

diabetes, number of patients with uncontrolled diabetes, view of knowledge about DSME

24

as a barrier, ease of referral to diabetes education, and physician-provided of diabetes

education?

o Null Hypothesis one (H02): Physicians’ referral behavior is not significantly

related to either physician’s length of time in practice, specialty, number of

patients with diabetes, number of patients with uncontrolled diabetes, view of

knowledge as a barrier, ease of education referral, and/or physician-provided

education.

o Alternative Hypothesis one (Ha1): Physicians’ referral behavior is significantly

related to either physician’s length of time in practice, specialty, number of

patients with diabetes, number of patients with uncontrolled diabetes, view of

knowledge as a barrier, ease of education referral, and/or physician-provided

education.

Research Question three (RQ3): What feedback can physician’s offer to diabetes

educators to improve the quality of DSME programs?

Summary

The chapter expands the conceptual framework and objectives guiding this study. The

physician’s role as gatekeeper to DSME is related to their ability to either refer or not refer a

patient with diabetes for education. The low referral rates and lack of a provider-centered

research are the motivating factors behind this project. One of the study’s objectives is to

determine the relationship between a physician’s length of time in practice, specialty, number of

patients with diabetes, number of patients with uncontrolled diabetes, amount of physician-

provided education, ease of referral, and physicians’ view of DSME knowledge as a barrier to

refer as predictors both directly and indirectly to referral behavior. The second objective is to

identify provider specific feedback regarding DSME and suggestions for improvement.

25

CHAPTER 4

METHODOLOGY

This is a descriptive study that will investigate both generalists and specialist’s

perceptions of DSME and determine which variables influence their knowledge of and barriers

to refer patients to this resource. An online survey was created then distributed from June

through August of 2016 to providers as the medium for data capture.

Setting

The chosen location for this study is a major teaching hospital affiliated with a university-

based academic health center. Physicians working in such settings see a large number of patients

daily and have a wide variety of medical resources available, including on campus diabetes

education programs.

Participants

The target population for this project are physicians who have a higher percentage of

patients with chronic illnesses, specifically diabetes. Some of the specific specialties that would

see patients with this disease include family medicine, general internal medicine providers, and

many subspecialties that stem from internal medicine such as endocrinology and cardiology.65,66

In order to reach a high volume of these specific physicians, the survey was emailed through the

hospital’s Department of Internal Medicine listserv. This listserv reaches 45 hospitalists, 30

generalists, and 100 subspecialties. The survey was also sent through a listserv containing

numerous primary care physicians also within the same university’s network of care. The sample

size was calculated based on this available information. From the total 175 potential physician

participants, the sample size is 62 with a 10% margin of error and a goal response rate of 30%.

26

Research Design

The study process began by collecting evidence relevant to the hypotheses of the study to

build the content of the survey. First, a meeting was held with the diabetes education program

manager associated with the study’s chosen setting to discuss what topics and inquiries are

crucial to the local diabetes community. Second, a literature review was performed to solidify the

content of the survey and to find previously created questionnaires as possible templates for this

study’s survey. After researching and collecting pertinent information, a preliminary survey was

constructed and stored in REDCap® (Research Electronic Data Capture). REDCap® is

innovative software that supports the development of data capturing tools such as surveys for the

purpose of clinical and translational research.67 The survey was then pilot tested by 3 unrelated

physicians who provided constructive feedback and assisted in finalizing the survey. Another

meeting was held with the chair of the Department of Internal Medicine to receive permission

and access to the department’s email listserv. Once access was granted and prior to sending the

survey, an online account was created containing 90 Starbucks e-gift cards that contained $5.00

each. A gift card would be sent to each physician who completed the survey in gratitude for their

response and to compensate for their time. A request to the Institutional Review Board was

submitted and promptly approved prior to initiating data collection. The survey was then sent to

physicians in the beginning of June 2016 with an additional reminder email sent every 2-3 weeks

until September of 2016. The completed surveys were stored in REDCap®. After this data

collection period, the process of analyzing the data began.

Survey Instrument

As previously mentioned, the chosen measurement tool was an online survey. A survey

was selected because of its ability to capture relevant information about a physician, understand

their perception of DSME, and make inferences based on their numerical as well as descriptive

27

responses. It is also an advantageous data collection method, specifically when working with

physicians, due to the flexibility it offers participants and the short amount of time required to

complete the survey.68 The final survey contains 56 items divided into 4 sections: 1) Patient Load

and Characteristics, 2) Knowledge about Diabetes Education, 3) Perception of Barriers to Refer

to Diabetes Education, and 4) Personal Demographics. Prior to beginning the survey, the

providers are prompted to read over the Informed Consent and sign an Agreement to participate

in the study. Overall, there are both quantitative and qualitative measures in the form of closed

and open-ended questions respectively.

The first section, Patient Load and Characteristics, is comprised of 6 categorical variable

questions, each with 7 multiple choice response options. Its objective is to determine what

percent of the physician’s daily patients have diabetes and what percent have uncontrolled

diabetes (HbA1c >8%). In addition, it asks providers what percent of these patients do they refer

to a DSME program.

Understanding the provider’s knowledge of DSME as a barrier is the focus for the second

section, Knowledge about Diabetes Education. The first question uses a Likert Scale (strongly

agree, agree, neutral, disagree, or strongly disagree) as responses to 4 listed statements

concerning: their awareness of patient educational resources, their educational referral behavior,

ease of the referral process, and whether they themselves provided diabetes education to their

patients. A Likert Scale was chosen in this as well as the following section of the survey because

the responses are quantifiable and easily manipulated for data analysis.69 Physicians were then

also asked three specific multiple choice questions regarding the Center for Medicaid and

Medicare Services (CMS). Physician knowledge of the CMS was included because Medicare

will reimburse up to 10 hours of diabetes education for patients with this insurance. After

28

completing these 10 hours, a patient may then qualify for up to 2 hours of additional training

each year after the initial training.70

The third section, Perception of Barriers to Referral to Diabetes Education, asks

participants to identify the frequency with which they consider 11 specific factors as a hindrance

when referring their patients to educational programs. These factors include the physician’s lack

of knowledge about DSME, their received feedback from patients who did attend DSME, the

difficulty of the referral process, and patient characteristics (socioeconomic status, health

literacy, insurance, race and ethnicity, motivation, access to transportation, and age). Physicians

were asked whether they never, rarely, occasionally, usually, or always consider each factor to be

a barrier when referring patients. They were then asked two open-ended questions to describe

and elaborate on why they believe the DSME program is underutilized as well as suggestions for

improvement.

In the final section of the survey, Personal Demographics, providers were asked 6 open-

ended as well as multiple choice questions related to their background, specifically, their age,

years of practice, specialty, gender, race, and ethnicity.

In reference to the study’s theoretical model, Table 4-1 provides an outline depicting

where each dependent and independent variable is located within the survey and what the

question is specifically asking the physicians. The complete survey is located in Appendix B.

Table 4-1. Variables of Interest Location in Survey

Variable Research Question Item on Survey

Knowledge of the Program

(DV1)

1 Question 1b in Section 3:

Lack of knowledge about the

program

Referral Behavior

(DV2)

2 Question 1b in Section 2: I

refer my patients with

uncontrolled diabetes for

education on a regular basis

29

Table 4-1. Continued

Variable Research Question Item on Survey

Length of Time in Practice

(IV1)

1,2 Question 2 in Section 4:

How long have you been in

practice?

Specialty (IV2) 1,2 Question 4 in Section 4: What

is your medical specialty?

% of Patients with Diabetes

(IV3)

1,2 Question 2 in Section 1: What

percent of your patients are

diagnosed with diabetes?

% of Patients with

Uncontrolled Diabetes (IV4)

1,2 Question 3 in Section 1: Of

those patients diagnosed with

diabetes, what percent have

uncontrolled diabetes

(HbA1c≥8)?

Physician-provided Education

(IV5)

2 Question 1c in Section 2: I

frequently provide diabetes

education to patients directly

during our interactions.

Ease of referral process (IV6) 2 Question 1d in Section 2: It is

easy to refer a patient to

diabetes education.

Statistical Analysis

Participants’ completed surveys were stored in REDCap® where the data was aggregated

into a spreadsheet and then exported into SPSS 24 for further data analysis.

Descriptive frequency tables were first tabulated on all categorical variables to detect the

general trends of responses and specific abnormalities between response ranges. Due to the small

predicted sample size, the 8 variables of interest were dichotomized a prior in order to reduce the

number of categories, increase cell sizes, and thereby enhance the ability to detect statistically

significant differences. Each question’s multiple choice responses were also grouped into 0 or 1

categories. The distribution of responses across the original categories was used to define 0-1

break points that created the most even distribution between responses when dichotomized. In

addition, physicians reported their specialty which was then coded into either a 0 or 1 based on

30

whether it was a subspecialty such as endocrinology or a general practice such as family

medicine, respectively.

Chi-square testing with the transformed data was then performed between key dependent

variables of the study and the independent variables that serve as predictors. This method of

analysis would determine the association between these variables and whether we could reject

the null or accept the alternative hypotheses. The first chi square test was between the dependent

variable, physician’s knowledge of DSME, and its four predicted independent variables. The

second chi-square test analyzed the interactions between the dependent variable, referral

behavior, and 7 other categorical variables.

A final quantitative investigation of the dichotomized variables was performed through

linear probability modelling. This type of analysis was chosen over binary logistic regression

modelling because it would be a more direct interpretation of the effect each regressor has on the

dependent variable and because of convergence issues in the maximum likelihood estimation

stemming from the small sample size. The coefficient for each X variable in the output expressed

either a decrease or increase in the probability of Y equaling 1.71 RQ1 would be addressed by

running a linear probability model to determine how physicians’ knowledge of diabetes

education varied based on physician’s length of time in practice, specialty, number of patients

with diabetes, and number of patients with uncontrolled diabetes. RQ2 would be addressed by

analyzing referral behavior as a function of physician’s length of time in practice, specialty,

number of patients with diabetes, and number of patients with uncontrolled diabetes, ease of

education referral, knowledge of diabetes education as a barrier to referrals, and physician-

provided education.

31

A qualitative analysis was conducted on physician’s responses to the 3 specific open-

ended questions located in the Knowledge of Diabetes Education and Perceived Barriers to Refer

sections of the survey. These questions prompted physicians to provide insight into why they

believe patients do not utilize DSME and suggestions for improvements to the program. A

thematic approach was taken in order to code the data in manner that summarizes the

participant’s beliefs and experiences when referring patients to DSME.72,73 Responses were first

divided into 1 of 2 generally themed groups, program related or patient related, which was

determined based on the overall content of physician replies. The responses that cited a structural

issue with the program or scheduling difficulties with the program’s staff were placed in the

program content group. Patient related responses are those that mentioned patient characteristics

as the cause of patient low adherence to the program such as low health literacy or lack of

transportation. Both groups were subdivided, again thematically, based on the specific content of

each physician’s response. Each answer that listed different themes was reported in multiple

categories. Figure 4-1 exemplifies this coding process. The frequency of responses in both

general and specific categories was tabulated to determine what physicians believe are the major

contributors to low patient attendance to DSME.

32

Figure 4-1. Thematic Coding Process

Summary

This chapter describes the methods chosen to accomplish the study’s objectives and

explains the rationale behind them. The target population included both generalists and

specialists from a large hospital setting. A research design outlined the process of creating and

distributing the survey. In addition, a detailed description of the survey’s content was described.

The first step in data analysis would begin with determining descriptive frequency tables to

understand the general trends of physician responses. The information from these tables also

assisted in dichotomizing the variables of interest. The quantitative analysis began by running

descriptive chi square tests between the study’s dependent variables and their associated

independent variables. Finally, a linear probability model would be run to determine what

probability each independent variable has in predicting the outcome of each dependent variable

after controlling for the effects of other independent variables. The survey’s qualitative data

would be analyzed by coding each physician’s written response into both general and specific

categories based on program and patient related themes. The frequency of physician responses in

Transportation (1)

Program Content (2)

Specific Themes

Patient related

Program related

General Themes

lack of transportation,

training not tailored to

their needs. The group

sessions can sometimes be

irritating for some patients,

some are quick some

are slow.

Response

33

each category would be calculated to determine what physicians believed to be responsible for

the lack of patient attendance to DSME.

34

CHAPTER 5

RESULTS

This segment reports the findings of the analyses outlined in the above methodology

section. The data analysis included creating descriptive frequency tables, checking construct

validity of the survey, running chi square tests, determining the best fit linear probability model,

and categorizing physician’s written in responses. The results from these multiple analyses will

answer this study’s research questions and assist in understanding a physician’s role as

gatekeeper to DSME.

Sample

The total number of survey responses includes 44 physicians with 23 generalists and 21

specialists indicating a 25% response rate. During the three-month data collection period,

multiple follow-up emails were sent to each participant in an effort to attain the highest response

rate possible. In Table 5-1 the specialties of the responding physicians and their frequencies are

shown. A relatively even amount of both generalist (23, 52.2%) and specialist (21, 47.7%)

completed the survey with general internal medicine representing the overall majority of

responses (13, 29.5%).

In addition, Table 5-2 highlights the distribution of physicians age and length of time in

practice which are both key demographics influencing a physician’s gained knowledge regarding

DSME. Physicians between the ages of 51-60 years old and those who have been practicing

between 0-10 years represent the plurality of physicians (31.8% and 34.1% respectively) by age

and length of time in practice, respectively.

35

Table 5-1. Frequency of Responses by Specialty

Variables Frequency Percent (%) Total Distribution

Generalists

General Internal Medicine

Hospital Medicine

Family Medicine

Total

13

1

9

23

56.5

4.3

39.1

100.0

29.5

2.27

20.5

52.3

Specialists

Endocrinology

Nephrology

Gastroenterology

Cardiology

Pulmonary

Oncology

Allergy

Integrative Medicine

Infectious Disease

Total

6

4

3

3

1

1

1

1

2

21

28.6

19.0

14.3

14.3

4.8

4.8

4.8

4.8

9.5

100.0

13.6

9.1

6.8

6.8

2.27

2.27

2.27

2.27

4.5

47.7

Table 5-2. Physician Demographics

Variables Frequency Percent (%)

Age

20-30 years

31-40 years

41-50 years

51-60 years

61-70 years

71-80 years

Total

1

12

12

14

3

2

44

2.3

27.3

27.3

31.8

6.8

4.6

100.0


0-10 years

11-20 years

21-30 years

31-40 years

41-50 years

51-60 years

Total

15

13

10

4

1

1

44

34.1

29.5

22.7

9.1

2.3

2.3

100.0

36

Data Consolidation

The current format of survey responses includes multiple categorical answer choices. The

responses associated with each independent and dependent variable needed to be reduced into

two categories due to the small sample size in order to proceed with the data analysis and

procure more statistically significant results. Frequency table findings indicated the most

appropriate method to split the response data. For the survey questions that had 5 multiple choice

options, the first two responses were represented by a zero and the remaining three were

represented by a one. For example, Question 1b in Section 2 asks physicians whether they

strongly agree, agree, are neutral towards, disagree, or strongly disagree with this statement, “I

refer my patients with uncontrolled diabetes on a regular basis.” If a physician marked either

strongly agree or agree, their response would be represented by a 0 in the data. The variables

referral behavior, physician-provided education, ease of referral, and knowledge of the program

in Table 5-3 underwent this specific data consolidation process. The remaining variables in Table

4, except specialty, had 6 multiple choice options. Therefore, the first three responses were

indicated by a 0 and the remaining three were indicated by a one. Responses for the variable

specialty were already separated into two categories as shown in Table 5-1. Each specialist was

denoted by a 0 and a 1 was given to each generalist.

37

Table 5-3. Dichotomized Variables

Descriptive Frequencies Concerning the Research Questions

The results displayed in Table 5-4 and 5-6 highlight the bivariate associations between

the dependent and independent variables involved in both research questions through chi-square

testing. Physicians knowledge of the program did not have any statistically significant

relationships (p-values >.05) with its potential predictor variables (length of time in practice,

specialty, percent of patients with diabetes, percent of patients with uncontrolled diabetes).

Although the differences in the point estimates were in the expected direction, the lack of

statistical significance is disappointing. Quite likely, the small sample size may have yielded

insufficient statistical power to detect the observed differences as significant.

Variables Frequency Percent (%)


0-30 years (=0)

31-60 years (=1)

38

6

86.4

13.6

Specialty

Specialist (=0)

Generalist (=1)

21

23

47.7

52.2


0-20% (=0)

21-50% (=1)

20

24

45.5

54.5

% of Patients with Uncontrolled Diabetes

0-20% (=0)

21-50% (=1)

24

20

54.5

45.5

Physician-Provided education

Strongly Agree/Agree (=0)

Neutral/Disagree/Strongly Disagree (=1)

34

10

77.3

22.7

Ease of referral



24

20

54.5

45.5

Knowledge of program

Never/Rarely (=0)

Occasionally/Usually/Always (=1)

23

21

52.2

47.7

Referral Behavior



29

15

65.9

34.1

38

Unlike the above results, physician referral behavior did have significant relationships

with 5 of the 7 tested variables: percent of patients with diabetes, percent of patients with

uncontrolled diabetes, physician-provided education, ease of referral, and knowledge as a barrier.

These outcomes suggest that those specific variables influence physicians’ referral decisions and

subsequently supports Ha2 which predicts that each of these variable will significantly impact a

physician’s decision to refer a patient to DSME.

Table 5-4. Chi Square Results for Knowledge as a Barrier (DV1)

Variable

(n=44)

Knowledge of DSME as a barrier to refer

Never/Rarely Occasionally/

Usually/Always

P


0-30 years

31-60 years

18 (47%) 20 (53%)

5 (83%) 1 (17%)

.101

Specialty

Specialist

Generalist

8 (38%) 13 (62%)

15 (65%) 8 (35%)

.072


0-20%

21-50%

8 (20%) 12 (60%)

15 (63%) 9 (37%)

.137


0-20%

21-50%

10 (42%) 14 (58%)

13 (65%) 7 (35%)

.123

39

Table 5-5. Chi Square Results for Referral Behavior (DV2)

Variable

(n=44)

Physician likelihood to refer patients with

diabetes to DSME

Strongly Agree/ Neutral/Disagree/

Agree Strongly Disagree

P


0-30 years

31-60 years

23 (61%) 15 (39%)

6 (100%) 0 (0%)

.058

Specialty

Specialist

Generalist

13(44%) 16 (55%)

8 (53%) 7 (47%)

.592


0-20%

21-50%

10 (50%) 10 (50%)

19 (79%) 5 (20%)

.042*

% of Patients with Uncontrolled

Diabetes

0-20%

21-50%

12 (50%) 12 (50%)

17 (85%) 3 (15%)

.015*


Strongly Agree/Agree

Neutral/Disagree/Strongly Disagree

23 (96%) 1 (4%)

6 (30%) 14 (70%)

.000**

Ease of referral



27 (79%) 7 (21%)

2 (20%) 8 (80%)

.000**

Knowledge as a barrier

Never/Rarely

Occasionally/Usually/Always

21 (91%) 2 (9%)

8 (38%) 13 (62%)

.000**

*p-value <.05

**p-value <.01

Linear Probability Models

Linear probability modeling was used to analyze both RQ1 and RQ2. RQ1 sought to

determine how physicians’ knowledge of diabetes education varies with length of time in

practice, specialty, percent of patients with diabetes, and percent of patients with uncontrolled

diabetes. A preliminary test that included all of the independent variables determined the strength

of the model. Table 5-7 shows that 3 out of the 4 predicted variables had a significant impact on

physicians’ knowledge of the program. The percent of patients with uncontrolled diabetes was

removed for a more parsimonious analysis and the results are shown in Table 5-7. The

40

coefficients represent the change in the probability of Y=1 when X changes from zero to one.

DV1 is the y variable and the category where Y=0 corresponds to physicians who rarely find a

lack of knowledge about DSME as a barrier to refer and Y=1 corresponds to physicians who

frequently find lack of knowledge about DSME as a barrier. For the independent variables, the

two response categories are written below the variable where the first response serves as the

reference group (X=0 indicated by a “-“ in Table 5-6, 5-8, and 5-9) and the second is the

intercept group (X=1) with DV1. The results show that physicians with longer lengths of practice

(31-60 years versus 0-30 years) have a 52% lower probability of reporting that knowledge of the

educational program is a frequent barrier to referral. Similarly, specialists and physicians with a

higher percentage of patients with diabetes (21-50% versus 0-20%) have a 29.5% and 34.8%

lower probability of reporting that knowledge of the educational program is a frequent barrier to

referral respectively.

Table 5-6. Preliminary Linear Probability Model for Knowledge as a Barrier (DV1)

Variable Coefficients

(Standard Error)


0-30 years

31-60 years

-

-.466* (.219)

Specialty

Specialist

Generalist

-

-.310* (.139)


0-20%

21-50%

-

-.299* (.155)


0-20%

21-50%

-

-.136 (.151) *p-value <.05

41

Table 5-7. Final Linear Probability Model for Knowledge as a Barrier (DV1)

Variable Coefficients

(Standard Error)


0-30 years

31-60 years

-

-.520* (.210)

Specialty

Specialist

Generalist

-

-.295* (.138)


0-20%

21-50%

-

-.348* (.145) *p-value <.05

The linear probability model for RQ2 involved a larger number of predictive variables

than RQ1. Multiple trails of variable exclusion, similar to RQ1, were performed to determine

which variables contributed to the most parsimonious model. As shown in Table 5-8, the

variables knowledge as a barrier, specialty, percent of patients with diabetes, and percent of

patients with uncontrolled diabetes did not have a significant effect on the probability of Y=1.

They were subsequently removed from the model based on their high p-values and negative

effect on the model’s reliability. The final equation then included 3 of the 7 original variables:

length of time in practice, physician-provided education, and ease of referral. Table 5-9 shows

the high statistical significance of each of these variables reassuring the model’s reliability. Like

the linear probability model for RQ1, the coefficients represent the change in the probability of

Y=1 when X changes from zero to one. However, the dependent variable is now measuring

physician referral behavior. Physicians who disagree to a statement asking if they frequently

refer a patient with uncontrolled diabetes to DSME daily is represented by Y=0 whereas

physicians who agree that they refer a patient with uncontrolled diabetes daily to DSME by Y=1.

According to the output shown in Table 5-8, there is roughly a 40.2% higher probability of Y=1

as physicians’ length of time in practice changes from X=0 (shorter practice lengths) to X=1

42

(longer practice lengths) after controlling for physician-provided education and ease of referral.

After controlling for all other variables, there remained a statistically significantly lower

probability of Y=1 (physician agreeing that they refer a patient to DSME) by 32.2% as physician

provided education changes from X=0 (physicians who do provide their own diabetes related

education) to X=1 (physicians who state they do provide their own education to patients). There

is a similar lower probability of Y=1 by 56.6% as X changes from 0 (physicians who do not find

the referral process difficult) to 1 (physicians who do find the referral process difficult). These

effects support the expected hypotheses that physicians with longer length of time in practice and

those who do not find the referral process difficult would increase a physician’s intention to

refer. However, it was not predicted that physicians who do provide their own diabetes education

to patients would be inclined to also refer patients to DSME.

Table 5-8. Preliminary Linear Probability Model Results for Referral Behavior (DV2)

Variables Coefficients

(Standard Error)


0-30 years

31-60 years

-

.387* (.152)

Specialty

Specialist

Generalist

-

-.095 (.099)


0-20%

21-50%

-

.078 (.109)


0-20%

21-50%

-

.088 (.102)




-

-.512* (.120)

Ease of referral



-

-.292** (.123)

Knowledge as a barrier

Never/Rarely

Occasionally/Usually/Always

-

-.067 (.123) *p-value <.05

43

**p-value <.01

Table 5-9. Linear Probability Model for Referral Behavior

Variables Coefficients

(Standard Error)


0-30 years

31-60 years

-

.402** (.131)




-

-.322** (.155)

Ease of referral



-

-.566** (.097) *p-value <.05

**p-value <.01

Qualitative Coding Analysis

Physicians were asked to provide specific written-in feedback regarding DSME

programs. In total there were 42 unique responses that were coded and placed into first a general

and then more specific category based on the themes present in each answer. When prompted

with the question “Why do you think certain patients who are referred to this program fail to

utilize this service,” physician replied with 5 comments related to the program inadequacies and

37 related to patient characteristics as shown in Figure 5-1. Among all the responses, motivation

and transportation were the two most listed as either the reason or a contributing factor to patient

underutilization with 30.1% attributing to transportation and 19% to motivation. Those who cited

motivation to be a key influence made comments stating that patients would “have decreased

motivation in between visits”, “lack interest”, and that patients simply “don’t care” about DSME.

These findings corroborate with the survey responses marked by each physician. In the

third section of the survey, Perception of Barriers to Refer to Diabetes Education, 36.2% and

42.6% of physicians reported they occasionally and always see patient’s motivation as a barrier

44

to referral. Physicians also reported that they occasionally or always see patient’s lack of

transportation as a barrier by 44.7% and 36.9% respectively.

Program content, although not the most noted, was addressed by a few providers who

stated that changes should be made to the program’s design. A general internal medical doctor

wrote that “patients report that the terminology used to discuss diet is difficult for them to

understand (e.g., grams, calories vs. actual review of meals, menus),” and an endocrinologist also

stated that a patient complained of a “prior bad experience; education is not tailored to their

needs and background.”

Figure 5-1. Coded Responses

Summary

A total of 44 physicians completed the survey, 23 generalists and 21 specialists. The

responses associated with the independent and dependent variables were separated into two

categories due to the small sample size. Chi square testing revealed that none of the independent

"Why do you think certain patients who are referred to this

program fail to utilize this service?"

Program Related (5)

Staff Services (3)

Program Content (2)

Patient Related (37)

Internal Influences

(11)

Motivation/Interest (8)

Understanding of Importance

(3)

External Influences

(26)

Transportation (13)

Economics (4)

Social (2)

Schedule and Access (7)

45

variables in RQ1 shared a significant relationship with physician’s knowledge of programs.

However, physician referral behavior shared a significant relationship with the percent of their

patients with diabetes, percent of patients with uncontrolled diabetes, physician-provided

education, ease of referral, and knowledge of the program. The output from the linear probability

tests indicated which independent variables had a significant impact on the probability of a

physician perceiving lack of knowledge as a barrier to refer and the probability of a physician’s

agreement or disagreement with the statement about the physician’s propensity of referring a

patient to DSME. The majority of physicians who provided written feedback to DSME stated

that a patient’s lack of motivation and transportation were the top reasons behind patient low

attendance to DSME.

46

CHAPTER 6

DISCUSSION

The following section will review the study’s research questions, make observations

based on the results, and identify their implications regarding a physician’s role as gatekeepers to

DSME. In addition, the limitations of this study and suggested future research topics will be

discussed.

Research Questions

This study queried how 7 physician-related factors influenced referral behavior through

both a direct and indirect pathway. RQ1 and RQ2 describe these separate quantitative approaches

in association with H1 and H2 which represent this study’s central hypotheses. RQ3 specifically

describes the qualitative approach to understanding what physicians believe to diminish patient

adherence to DSME.

RQ1: How does physicians’ view of knowledge about DSME as a barrier vary with

length of time in practice, specialty, number of patients with diabetes, and number of

patients with uncontrolled diabetes?

H1: Physician’s view of DSME as a barrier to refer is significantly related to either

physician’s length of time in practice, specialty, number of patients with diabetes, and/or


Results from chi square testing indicate a failure to reject the above hypotheses.

However, linear probability modelling shows that generalists, physicians with longer practice

lengths, and with physicians a larger percent of patients with diabetes have a significantly lower

probability of reporting lack of program knowledge as a barrier to referral by 29.5%, 52%, and

34.8% respectively, compared to specialists, those physicians with shorter practice lengths, and

those physicians with a smaller percent of patients with diabetes, respectively. The results of the

linear probability models quantify each predictor’s individual effect when controlling for all

other variables, whereas chi square tests only examine unconditional bivariate relationships. This

47

shows that the more statistically significant and conclusive results stem from the linear

probability model.

RQ2: How is physicians’ perceptions of their propensity to refer their patients to DSME

related to their length of time in practice, specialty, number of patients with diabetes,

number of patients with uncontrolled diabetes, lack of knowledge as a barrier, ease of

referral to diabetes education, and physician-provided of diabetes education?

H2: Physician’s referral behavior is significantly related to either physician’s length of

time in practice, specialty, number of patients with diabetes, number of patients with

uncontrolled diabetes, lack of knowledge as a barrier, ease of education referral, and/or

physician-provided education.

The results for the chi square tests regarding RQ2 show the distribution of Y differs

across X=0 and X=1 for each X listed. Percent of patients with diabetes, percent of patients with

uncontrolled diabetes, physicians-provided education, ease of referral, and lack of knowledge as

a barrier were all marked as being highly associated with physician referral. The linear

probability model results showed physicians with longer lengths of practice to have a 40% higher

likelihood of Y=1 than when X=0 referring a patient to DSME. In addition, this model indicated

physicians who do not provide their own diabetes education to patients and physicians who find

the referral process difficult have a 32% and 56% lower probability of Y=1 than when X=0

referring a patient to diabetes education. The discrepancy between the descriptive and regression

results is again due to the unconditional and conditional nature of the relationships between the

dependent and independent variables in each test. The significant relationships between referral

behavior and the 5 other independent variable is a multidimensional analysis and does not

provide as much information as does the linear probability model. Descriptively, there is a strong

association between knowledge as a barrier and referral behavior based on the chi square results,

but there is no direct impact on the probability of referral as indicated by the linear probability

model findings. Therefore, additional factors may be driving the decision to refer through a

physician’s knowledge of diabetes educational programs.

48

RQ3: What feedback can physician’s offer to diabetes educators based on their perceived

issues surrounding DSME and do they have any suggestions regarding program

improvement?

Physicians cited patient external influences as the overall largest contributors to patient

underutilization of DSME. However, the two most frequent reasons were patients’ lack of

transportation (an external influence) and motivation (an internal motivation). These findings

provide diabetes educators with new insight regarding low patient attendance to DSME from the

physician’s perspective. An additional reason for patient underutilization noted by 3 physicians

(2 general internal medicine doctors and 1 gastroenterologist) was patient’s lack of

understanding regarding the importance of DSME. Although it was not the most listed cause for

patient low adherence, it is a significant finding that relates to previously done research on this

topic.8,52,54

Conclusions

The study provides insight into a physician’s role as gatekeeper to DSME. The length of

time in practice proved to be the most significant variable since it had both an indirect and direct

effect on the probability of referral. Physicians with longer practice lengths are less likely to

report lack of knowledge as a barrier by 52% and have a 40% higher probability of referring a

patient to diabetes education. These outcomes support and add to the findings in Cowen et al.

which determined that physician’s age and years out of medical school impact the likelihood of

referral.58 Physicians with a higher percent of patients with diabetes impacts referral behavior

indirectly due to a 34.8% lower probability of viewing knowledge as a barrier and directly

through a strong relationship as indicated by the chi square results in Table 5-5.

Because physicians are the gatekeepers to DSME, their views on diabetes education is

central to the referral process. According to previous research, physicians who provide their own

education to patients with diabetes were found to be less inclined to refer.12,19 However, this

49

study found that physicians who provide patient education may see referral to diabetes education

as complementary to their own education efforts. Not surprisingly, physicians who do not find

the referral process difficult perceive themselves as more likely to refer their patients with

diabetes. Although specialty was not found to directly impact referral behavior, there was a

29.5% lower probability that generalists viewed lack of knowledge as a barrier to refer. While

this may imply that generalists have an indirect effect on the probability of referral, there is no

evidence due to the lack of a statistically significant association between knowledge as a barrier

and referral behavior.

Physician referral patterns are a direct representation of a provider’s role as gatekeepers

to DSME. Generalists, those with longer lengths of practice, a higher percentage of patients with

diabetes, and provide their own diabetes education to patients, find it easy to refer patients. Thus

those specific physicians are more likely to be effective gatekeepers as a gatekeeper is defined as

the process of matching patients’ needs and preferences to the judicious use of medical

services.56 By administering referrals to patients with diabetes, these patients are more likely to

experience the listed benefits of DSME such as a lower HbA1c, weight loss, psychological

support, and decreased medical costs.33,34,36,37,41,47,49 Therefore, in order to increase referrals,

efforts should be made to educate younger physicians who have been not been practicing

medicine for a long length of time. Residents studying to become endocrinologists or other

internal medicine subspecialties would be a preferred physician target population to administer

such educational interventions due to their shorter length of time in practice, smaller patient load,

and reduced experience working with patient with diabetes.

A physician’s effectiveness as a gatekeeper is also impacted by their views regarding

patient underutilization. Patients with a low perceived benefit of attending DSME is a known

50

cause of diminished DSME adherence rates even after being referred to the program.8,51–54,74 One

of the most cited reasons behind low perceived benefits was attributed to a lack of physician-to-

patient communication regarding the benefits of DSME.8,52,54 However, based on this study’s

qualitative analyses, physicians believe patient’s lack of transportation and low motivation are

two of the main sources behind the issue of patient underutilization as well as significant barriers

to refer. Three physicians also stated that patients do not attend DSME because they do not

understand the importance of this resource. Based on this information, both patients and the

physicians find fault in the other in regards to low attendance to DSME. While some patients

may appear to lack the motivation to participate in this service, it should be the physician’s role

as gatekeeper to not only refer patients but to communicate the importance of DSME as well as

use techniques of motivational interviewing to assess their readiness to attend.

Limitations

There are several limitations that merit discussion. The largest limitation effecting the

outcomes of this study stems from the small sample size of physicians that responded. This

common constraint restricts the external validity and generalizability of the study’s results.75–77

In addition, selection bias and institutional conflicts may have impacted the findings because

physicians who tend to care about diabetes education may have been more inclined to complete

the survey just as well as physicians who have had negative interactions with the DSME

program. Ultimately, the summation of these limitations impact the definitive nature of the

extrapolated conclusions. If the data concerning the total number of referrals made by physicians

was available, more definitive statistical information could have been extrapolated from survey

responses. However, as a descriptive study, the results offer additional insight into physician’s

perceptions of DSME and proposes what type of provider should be the focus of future physician

interventions to increase referrals made to diabetes education.

51

Future Research

Low referral rates to DSME is a prevalent issue causing low patient adherence to DSME.

Based on the results of this study, future research should be done to delineate the relationship

between lack of knowledge as a barrier and referral behavior by calculating the total number of

referrals distributed to patients. Additionally, creating and determining the efficacy of a novel

intervention designed to teach residents in an internal medicine subspecialty program about

DSME could be a beneficial method to increase referral rates. This intervention should inform

physicians about the benefits of DSME, how to refer patients, and ways to motivate patients to

attend these programs.

52

APPENDIX A

INFORMED CONSENT

Dear Provider,

We are seeking your input to improve the patient referral process to the diabetes education programs. This

program provides patients with diabetes education and teaches effective management strategies. Your

responses to this survey will help us improve your access to the program and its ability to serve your

patients.

Completion of this survey will take approximately 10 minutes of your time.

Upon completion of the survey, you will receive a link to a Starbucks Gift certificate code to redeem

for $5 dollars as compensation and gratitude for your time.

Your participation is voluntary and your answers will be kept strictly confidential. Results will be

reported in aggregate form.

Please continue on to read the Informed Consent below, and mark on the survey instrument

whether you agree to participate according to these terms.

53

APPENDIX B

SUVEY SAMPLE

Provider Survey on Referral Process to Diabetes Education

Programs

Informed Consent

After reading the Informed Consent document, please complete the Agreement Section here.

"I have read the procedure described above. I voluntarily agree to participate in the procedure

and I have received a copy of this description."

By marking "I agree" below, you confirm that you are between above 18 years old, have read

and understand this consent form, and voluntarily agree to participate in this study.

I Agree I Do Not Agree

Provider Survey

This purpose of this provider survey is to better understand the referral process to diabetes

education. The survey contains both closed and open-ended questions and should take no more

than 10 minutes to complete. Throughout each section, the term "diabetes" encompasses both

type 1 and type 2. The questions focus on five subjects: (1) descriptive characteristics of your

patient load (2) patient-provider interactions (3) knowledge about resources available for

diabetes education (4) perceived barriers to referring patients to diabetes education and (5)

provider demographics.

Your responses to survey questions will be de-identified, kept anonymous and only presented in

aggregate form.

Section 1: Patient Load, Characteristics, and Interaction Time

1) On an average day, what is your typical patient load?

a. none

b. 1-5

c. 6-10

d. 11-15

e. 16-20

f. 21-25

g. Other:

2) What percent of your patients are diagnosed with diabetes?

a. 0%

b. 1-10%

c. 11-20%

d. 21-30%

e. 31-40%

f. 41-50%

54

g. Other:

3) Of those diagnosed diabetic patients, what percent have uncontrolled diabetes (HbA1c ≥

8%)?

a. 0%

b. 1-10%

c. 11-20%

d. 21-30%

e. 31-40%

f. 41-50%

g. Other:

4) Of your patients with diabetes, what percent of them are on insulin?

a. 0%

b. 1-10%

c. 11-20%

d. 21-30%

e. 31-40%

f. 41-50%

g. Other:

5) Of your patients with diabetes, how many do you refer to the Diabetes Self-Management

and Nutrition Therapy for diabetes education?

a. 0%

b. 1-10%

c. 11-20%

d. 21-30%

e. 31-40%

f. 41-50%

g. Other:

6) How much time do you spend with your typical patient for face-to-face counseling?

a. 1-5 minutes

b. 6-10 minutes

c. 11-15 minutes

d. 16-20 minutes

e. 21-25 minutes

f. More than 25 minutes

55

Section 2: Knowledge about Diabetes Education

1. These questions investigate your knowledge about the diabetes education program.

Please mark the best answer.

Strongly

Agree

Agree Neutral Disagree Strongly

Disagree

a. I am aware of the resources available for

Diabetes Education

b. I refer my patients with uncontrolled

diabetes for education regularly.

c. I frequently provide diabetes education to

patients directly during our interactions.

d. It is easy to refer a patient for diabetes

education.

1e. If you have any additional information or would like to explain your responses to the

previous question, please do so below.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________

2. Are you familiar with the Center for Medicaid and Medicare Service’s (CMS) guidelines in

regards to diabetes education?

a. Yes I am very familiar

b. Yes I am slightly familiar

c. Neutral

d. No I am not very familiar

e. No I am not familiar at all

3. According to the CMS, how many months do newly diagnosed patients with diabetes have to

initiate diabetes education?

a. 18

b. 12

c. 6

d. 5

e. I don’t know

4. According to the CMS, how many hours of diabetes education are required for patients (1) to

complete the diabetes education program and (2) to qualify for 2 additional hours each year

thereafter?

a. 15

56

b. 12

c. 10

d. 8

e. I don’t know

Section 3: Perceptions/Barriers about Referring Patients to Diabetes Education

1. Please select the frequency to which these factors pose as barriers when deciding

whether to refer or not to refer a patient to diabetes education.

Never Rarely Occasionally Usually Always

a. Lack of time to make referral

b. Lack of knowledge about the program

c. Negative patient feedback for the program

d. Difficult referral process through EPIC

e. Patient with low socioeconomic status

f. Patient with low health literacy

g. Patient with no insurance

h. Patient’s race and ethnicity

i. Patient’s lack of motivation

j. Patient’s lack of access to transportation

k. Patient’s age

2. How do you personally define a patient with low health literacy? (Circle all that apply)

a. Less than high school education

b. Patients with higher educational degrees but little health background

c. Patients with a little experience with or knowledge of illness/disease

d. Other (please specify): : ___________________________________________

3. How do you personally define low socioeconomic status? (Circle all that apply)

a. Patients from rural areas

b. Patients without insurance

c. Patients from minority communities

d. Patients with low income

e. Other (please specify): : ___________________________________________

57

4. At what age do you think a patient is too old to refer for diabetes education?

a. Never too old

b. 60-65 years

c. 66-70 years

d. 71-75 years

e. 76-80 years

f. More than 80 years

g. Other (please specify): : ___________________________________________

5. Why do you think certain patients who are referred to this program fail to utilize this

service?

________________________________________________________________________

________________________________________________________________________

6. If you have experienced difficulty referring patients, do you have any suggestions that

would help to improve this process?

________________________________________________________________________

________________________________________________________________________

Section 4: Personal Demographics

1) What is your age?

a. 20-30 years

b. 31-40 years

c. 41-50 years

d. 51-60 years

e. 61-70 years

f. 71-80 years

2) How long have you been in practice?

a. 0-10 years

b. 11-20 years

c. 21-30 years

d. 31-40 years

e. 41-50 years

f. 51-60 years

3) What is your medical background?

a. Doctor of Medicine (M.D)

b. Doctor of Osteopathic Medicine (D.O)

c. Other:

4) What is your medical specialty?

58

________________________________________________________________________

5) What is your gender?

a. Male

b. Female

c. Other:

6) What Race do you identify with? (Check all that apply)

a. White

b. Black or African American

c. Asian

d. American Indian or Alaska Native

e. Native Hawaiian or Other Pacific Islander

f. More than one race

g. Other:

7) Are you Hispanic?

a. Yes

b. No

59

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BIOGRAPHICAL SKETCH

Shannon graduated cum laude from the University of Florida in 2015 with a Bachelor of

Science in biology and a minor in nutritional sciences. Throughout her time as an undergraduate,

she gained valuable research experience as an assistant in the University of Florida’s Pediatric

Psychology lab, Diabetes Institute, and Institute for Child Health Policy. Shannon then earned

her Master of Science in medical sciences with a concentration in health outcomes and policy.

Documents

To my family who has never doubted my ability to succeedufdcimages.uflib.ufl.edu/UF/E0/05/12/13/00001/TAYLOR_S.pdf · to refer or not to refer: an evaluation of provider perceptions