The Missed Patient With Diabetes

This study examined the association between access to health care and three classifications of diabetes status: diagnosed, undiagnosed, and no diabetes. Using data from the 1999-2004 National Health and Nutrition Examination Survey, we identified 110 "missed patients" (fasting plasma glucose >125 mg/dl but without diagnoses of diabetes), 704 patients with diagnosed diabetes, and 4,782 people without diabetes among adults aged 18-64 years. The population percentage undetected among adults with diabetes and the odds ratio of being undetected among adults who reported not having diabetes were compared between groups based on their access to health care.

The results showed that, among those with diabetes, the percentages having undetected diabetes were 42.2% (95% CI 36.7-47.7) among the uninsured, 25.9% (22.9-28.9) among the insured, 49.3% (43.0-55.6) for those uninsured >1 year, 38.7% (29.2-48.2) for those uninsured ≤1 year, and 24.5% (21.7-27.3) for those continuously insured over the past year. Type of insurance, number of times receiving health care in the past year, and routine patterns of health care utilization were also associated with undetected diabetes. Multivariate adjustment indicated that having undetected diabetes was associated with being uninsured (odds ratio 1.7 [95% CI 1.0-2.9]) and with being uninsured >1 year (2.6 [1.4-5.0]).

We found that those covered by private plans were significantly more likely to be undiagnosed when they actually had diabetes than were those covered by government insurance. This finding may seem counterintuitive, but we know that some private insurance companies provide limited coverage for preventive care, and private coverage tends to be more discontinuous. It is worth noting that some government health plans (e.g., those offered through the Department of Veterans Affairs) provide relatively effective preventive care for their enrollees with diabetes, and the Veteran’s Affairs professional staff may accordingly be more attuned to recommendations for diabetes screening.

Previous studies have not found a relationship between education or income and the risk of having undetected diabetes. These studies, however, did not examine the role played by access to health care (another aspect of socioeconomic status) in the detection of diabetes. Although we found no significant difference by education or income between being diagnosed and undiagnosed among individuals with diabetes, our analyses have shown that access to health care plays an important role in detecting diabetes.

Although race/ethnicity is related to diabetes and poor access to care, we found no evidence that race/ethnicity affects the association between access to health care and detection of diabetes. A recent study, using data from Behavioral Risk Factor Surveillance System 1998-2001, found that individuals of lower socioeconomic status were at greater risk for not receiving preventive care regardless of race/ethnicity and those without health insurance coverage were at the greatest risk for not receiving preventive services. Our findings are consistent with that study. In our model, lack of access to health care is a predictor for undetected diabetes regardless of race/ethnicity. Our study suggests that access to health care might be among the most important predictors for determining whether diabetes is/is not detected.

Having undetected diabetes puts one’s health at substantial risk,[1,2] but timely detection of diabetes is difficult without access to health care. Using a nationally representative sample, we found that lack of access to care significantly elevated the risk of going undiagnosed. We found that undetected diabetes was related to insurance coverage, routine patterns of health care utilization, and continuity of coverage. The type of insurance and the number of times a health care professional was seen in the past year were also associated with having undetected diabetes. It is also noteworthy that those with undiagnosed diabetes were significantly more likely than those without diabetes to be uninsured or to be uninsured for >1 year.

From the results it was concluded that limited access to health care, especially being uninsured and going without insurance for a long period, was significantly associated with being a "missed patient" with diabetes. Efforts to increase detection of diabetes may need to address issues of access to care.

With the increases in both the diabetic and the uninsured populations in the U.S., it seems very likely that the number of undetected cases of diabetes will increase in the future, with consequent increases in diabetes-related morbidity and mortality. This trend cannot be reversed until we can increase access to health care for those Americans who need it most. Our analyses indicate that limited health care access, especially being uninsured and having a long period without insurance, is associated with being a "missed patient" with diabetes. Those making an effort to increase the timely detection of diabetes should consider issues related to health care access.

Our findings demonstrate that lack of access to health care may result in missed opportunities to detect diabetes. The detection of diabetes requires specific diagnostic tests, e.g., the fasting plasma glucose test or the oral glucose tolerance test (or both). These tests are commonly arranged within a comprehensive health care setting that recognizes the risk profiles of its patients. Without access to comprehensive health care, patients would be less likely to receive screening and diagnostic services, and, in the end, their diabetes may be missed by the health care system. When they are missed by the health care system, the problems caused by those "missed" cases do not disappear. On the contrary, as a study by Young and Mustard indicated, they represent the unseen but clinically important burden of diabetes, with significant concurrent metabolic derangements and a long-term impact on use of health care.

Diabetes Care.  2008;31(9):1748-1753.