Research Article: Can diabetes patients seeking a second hospital get better care? Results from nested case–control study

Date Published: January 22, 2019

Publisher: Public Library of Science

Author(s): Jae-Hyun Kim, Eun-Cheol Park, David Alejandro González-Chica.


This study investigates the effects of the number of medical institutions visited on risk of death. This study conducted a nested case-control design using the National Health Insurance Service–Senior database from 2002 to 2013. Cases were defined as those with death among outpatients who had first diagnosis of diabetes mellitus (E10-E14) after entry into the base cohort and controls were selected by incidence density sampling and matched to cases based on age, and sex. Our main results were presented by conditional logistic regression for nested case-controls design. Of total 55,558 final study samples, there were 9,313 (16.8%) cases and 46,245 (83.2%) controls. With an increase by one point in the number of hospitals per medical utilization, risk of death significantly increased by 4.1% (odds ratio (OR): 1.041, 95% confidence interval [CI]: 1.039–1.043). In both medical utilization and number of hospitals, those with high medical utilization (OR: 1.065, 95% CI: 1.059–1.070) and number of hospitals (OR: 1.049, 95% CI: 1.041–1.058) for risk of death were significantly higher than those with low medical utilization (OR: 1.040, 95% CI: 1.037–1.043) and number of hospitals (OR: 1.029, 95% CI: 1.027–1.032), respectively. The number of medical institution visited was significantly associated with risk of death. Therefore, diabetics should be warned about the potential of risk of death incurred from excessive access to medical utilizations.

Partial Text

Diabetes mellitus is one of the foremost public health issues worldwide, especially in Korea which affects more than 25% of people over 60 [1]. It could increase the risk of chronic diseases such as cardiovascular disease,[2] retinopathy[3], renal failure,[4] and peripheral vascular disease and become a significant cause of morbidity and mortality in Korea[5].

Table 1 shows the general characteristics after incidence density sampling. Of 55,558 outpatients with diabetes mellitus, there were 9,313 cases (16.8%) with a death event. Mean age of (p = 0.705) and percent of male (p = 0.996) was 76.7 year-old in both case and control and 50.1%, respectively. Mean of number of hospitals per medical utilization was 19.2 (SD:16.4) in cases and 13.4 (SD: 9.4) in controls (Table 1). Table 2 presents the results of conditional logistic regression for death. Metropolitan, those with complexity disease, low income, those with insulin-dependent diabetes mellitus, medical aid beneficiaries and those with severe disability were associated with increased risks of death compared to urban, those with no complexity disease, high income, other specified diabetes mellitus, workplace insurance, and those with moderate disability, respectively. With an increase in one point in the number of hospitals per medical utilization, risks of death significantly (Odds ratio (OR): 1.041, 95% confidence interval [CI]: 1.039–1.043) increased by 4.1% after adjusting for all confounders. (Table 2).

Diabetes mellitus has experienced an explosive increase in prevalence during the last three decades in the Asian population[20]as well as Korean population[1]. In Korea, because the health care delivery system under the national health insurance coverage, with its high availability and accessibility of medical care services, places no restrictions on visits to medical institutions. This allows the excessive access to all institutions and doctors, resulting in lower continuity of care that was associated with lower quality of care, and increased health care utilization and costs [21]. Disease progression or recurrence from low quality of care may be potentially associated with not receiving timely and proper treatment. As a result, progression of disease representing a severely worsening condition may cause a strong tendency toward excessive access to medical institutions.

In conclusion, our study shows that excessive access to medical utilizations was positively associated with the risk of death. Therefore, outpatients with diabetes mellitus should be warned about the potential risk of death incurred from excessive access to medical utilizations. In addition, based on previous studies[23], because, much more trusting, stronger sense of affiliation and communication with their physicians may contribute to cessation of duplicated medical care utilization through improved patient satisfaction and quality of care, health education programs are needed to modify unrealistic views and provide a better quality of care to patients.




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