PhD Candidate University of Alberta, Faculty of Pharmacy and Pharmaceutical Sciences Edmonton, Canada
Background: Processes of care, such as the prescribing decisions that clinicians make when managing disease, is an important, understudied factor associated with the differences between rural and urban healthcare. Building on this, our study evaluated guideline concordant processes of cholesterol management of newly treated type 2 diabetes by place of residence (metropolitan/urban/rural), based on the recommendations from the Canadian Diabetes Association 2013 Clinical Practice Guidelines.
Objectives: We hypothesized that rural-dwelling individuals would be less likely to receive lipid laboratory monitoring or a statin dispensation within the first year of type 2 diabetes management, compared to metropolitan-dwellers.
Methods: We used a retrospective cohort study design with administrative data to examine anonymized patient health records between 1 April 2015 and 31 March 2020 in Alberta, Canada. Adult new metformin users were followed for the first year of their type 2 diabetes management. Place of residence was identified using postal codes. We used multivariable logistic regression to examine the association between lipid laboratory monitoring and place of residence, as well as the association between statin dispensations and place of residence. A sensitivity analysis was performed by excluding those with statin use prior to first metformin dispensation.
Results: Of the 60,222 new metformin users, the mean age was 55 years at first metformin dispensation and 57% were male. At first metformin dispensation, area of residence was distributed as 67% metropolitan, 10% urban, and 23% rural. Considering patient characteristics, comorbid conditions, and concurrent medications, rural residence was associated with a significantly lower likelihood of lipid laboratory monitoring and statin use within the first year of type 2 diabetes management, compared to metropolitan residents (aOR: 0.86; 95% CI: 0.83-0.90) and (aOR: 0.83; 95% CI: 0.79-0.87), respectively. When prevalent statin users were excluded, rural residence continued to be associated with a significantly lower likelihood of statin use (aOR: 0.80; 95% CI: 0.76-0.85).
Conclusions: While cholesterol management is only one measure of guideline recommended type 2 diabetes care, this study highlights the differences in management experienced according to place of residence. The limited adherence to guideline recommended cholesterol management in rural areas is a concerning observation which may result in jeopardized cardiovascular outcomes. Examining other guideline concordant processes of care by place of residence is planned in future analyses as well as health outcomes research.
