Utilization of primary care physicians by obese men and women: Review for Germany and results from the Monica/Kora Cohorts S3/F3 and S4/F4

Abstract

To provide a review on the obesity-associated utilization of outpatient primary care physicians (PCPs) by adults in Germany, analyze associations between moderate and severe obesity and the utilization of outpatient PCP care, and systematize the results using the behavioral model of health services use. Methods For the review, a literature search was conducted in PubMed for the print publication period of January 1, 1998 to December 31, 2012, and adults as the target group. The first author assessed these publicationsby screening titles, abstracts, and, if necessary, full texts. For the empirical study, self-reported PCP data were collected within twopopulation-based cohorts (baseline surveys: Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA)-S3 1994/95 and Cooperative Health Research in the Region of Augsburg (KORA)-S4 1999/2001; follow-ups: KORA-F3 2004/05 andKORA-F4 2006/08) in the region of Augsburg, Germany, and were pooled for present purposes. Adults (N = 5,171)aged 25-64 years at baseline participated. Thenumber of visits to PCPat follow-up was compared across four groups defined by body mass index (BMI) at baseline. Body weight and height were measured anthropometrically. Hierarchical generalized linear negative binomial regressions adjusted for age at baseline, school education, survey cohort, and diabetes status were conducted. Results First, the review of population-based studies on obesity-associated PCP utilization found significantly higher use in obese than in nonobese groups as measured by the number of visits per annum. Second, the analysis of data from the MONICA/KORA cohorts S3/F3 and S4/F4 showed that women had almost one-third (31.3%) more PCP visits than men, and PCP visits linearly increased with the BMI group, with the highest mean number of PCP visits in severely obese individuals (4.7 vs. 2.8 in normal weight). Third, among women, all overweight groups had more PCP visits than the normal-weight group (4.3, 4.5, and 5.0, vs. 3.1). Among men, those with severe obesity reported higher utilization than the other three BMIgroups (4.4 vs. 2.6 in the normal-weight group, 2.8 in the preobesity group, and 3.1 given moderate obesity). Conclusion In population-based studies in Germany, obesity is associated with excess utilization of PCPs in terms of number of visits, holding especially for severe obesity. Excess PCP utilization is associated only with severe obesity among men, but with all three degrees of overweight among women. This pattern parallels obesity-associated reduction in physical health-related quality of life. Future studies should replicate these findings and examine the roles of enabling and contextual factors in this context, for instance, income as an effect modifier and the gender-specific impact of regional PCP density.