PREVENT-D: Post ACA Reform: Evaluate Community Health Center Care for Diabetes

 描述(申请人提供)：糖尿病(DM)是一种流行的和破坏性的慢性疾病，在美国有2900万人受到影响。医疗保险和持续获得医疗保健服务对于最佳的糖尿病护理和管理至关重要；因此，假设平价医疗法案(ACA)医疗补助的扩大可以大大改善糖尿病风险患者或已被诊断为糖尿病(有糖尿病风险或DM)的患者获得医疗保险和医疗服务的机会。ACA呼吁每个州在2014年前大幅扩大医疗补助覆盖范围；目前尚不清楚ACA医疗补助扩大对糖尿病风险患者的预防、治疗、支出和结局的影响。在2012年的一次法律挑战中，美国最高法院裁定，各州不需要实施ACA医疗补助计划的扩大；因此(到2015年1月1日)，28个州和哥伦比亚特区扩大了医疗补助计划，而22个州没有扩大。这一“自然实验”提供了一个独特的机会，让我们了解医疗补助的扩大是否以及在多大程度上会影响糖尿病风险患者的医疗保健机会和服务。我们将利用这一史无前例的自然实验来扩大我们对医疗补助扩大如何影响糖尿病预防、治疗、支出和健康结果的理解。我们将使用来自高级临床数据研究网络的电子健康记录(EHR)数据，该网络拥有来自718个社区卫生中心(CHC)的数据，其中包括12个Medicaid扩展州的470个CHC和9个非扩展州的248个CHC。从这个数据集中，我们将收集有关医疗保险、服务接收和健康结果变化的详细信息，数据跨越9年(扩展前和扩展后)，比较扩大医疗补助的州和没有扩大的州。此外，在我们之前工作的基础上，我们将把俄勒冈州213家高级CHC的EHR数据与俄勒冈州医疗补助索赔数据联系起来，以评估糖尿病风险患者的医疗补助支出。具体目标如下：目标1.比较扩张期与非扩张期糖尿病风险或糖尿病患者的保险前状况、总体就诊情况和慢性病管理就诊情况。目的2.比较扩张期和非扩张期糖尿病高危患者和非糖尿病患者接受初级和二级糖尿病预防服务(如肥胖、血脂水平、糖化血红蛋白)的效果。目的3.在扩大医疗补助的州，比较新参保(在后期获得医疗补助)、已经参保(在前期和后期获得医疗补助)和持续未参保(前期和后期)的DM风险患者或DM患者的DM相关生物标记物(例如，体重指数、血压、血脂水平)在治疗前的变化。目的4.测量俄勒冈州新投保患者和已投保糖尿病风险患者的医疗补助支出在投保前的变化。研究结果将与政策和实践相关，为美国医疗体系的进一步改进提供信息，以确保弱势人群获得医疗服务，并缩小糖尿病预防、治疗和健康结果方面的差距。

 DESCRIPTION (provided by applicant): Diabetes mellitus (DM) is a prevalent and devastating chronic disease, affecting >29 million people in the United States (US). Health insurance and continued access to healthcare services are essential for optimal DM care and management; therefore, it is hypothesized that Affordable Care Act (ACA) Medicaid expansions could substantially improve access to health insurance and healthcare services for patients at risk for DM or already diagnosed with DM (`with DM risk or DM'). The ACA called for every state to significantly expand Medicaid coverage by 2014; little is yet known about the impact of ACA Medicaid expansion on the prevention, treatment, expenditures, and outcomes of patients with DM risk or DM. In a 2012 legal challenge, the US Supreme Court ruled that states were not required to implement ACA Medicaid expansions; thus (by January 1, 2015), 28 states and the District of Columbia expanded Medicaid, while 22 states did not. This `natural experiment' presents a unique opportunity to learn whether and to what extent Medicaid expansion can affect healthcare access and services for patients with DM risk or DM. We will use this unprecedented natural experiment to expand our understanding of how Medicaid expansion impacts DM prevention, treatment, expenditures, and health outcomes. We will use electronic health record (EHR) data from the ADVANCE clinical data research network, which has data from 718 community health centers (CHCs), including 470 CHCs in 12 Medicaid expansion states and 248 CHCs in 9 non-expansion states. From this dataset, we will collect detailed information on changes in health insurance, service receipt, and health outcomes, with data spanning 9 years (pre- and post-expansion), comparing states that expanded Medicaid, and those that did not. Moreover, building on our prior work, we will link EHR data from 213 Oregon ADVANCE CHCs to Oregon Medicaid claims data to assess Medicaid expenditures among patients with DM risk or DM. The specific aims are as follows: Aim 1. Compare pre-post insurance status, overall visits, and chronic disease management visits among patients with DM risk or DM, in expansion versus non-expansion states. Aim 2. Compare pre- post receipt of primary and secondary DM preventive services (e.g., screening for obesity, lipid levels, glycosylated hemoglobin) among patients with DM risk or DM, in expansion versus non-expansion states. Aim 3. Compare pre-post changes in DM-related biomarkers (e.g., body mass index, blood pressure, lipid levels) in patients with DM risk or DM among newly insured (gained Medicaid in post-period), already insured (had Medicaid coverage in pre- and post-period), and continuously uninsured (pre- and post-period) patients in states that expanded Medicaid. Aim 4. Measure pre-post changes in Oregon Medicaid expenditures among newly insured compared to already insured patients with DM risk or DM. Findings will be relevant to policy and practice, informing further improvements in the US healthcare system to ensure access for vulnerable populations and mitigate disparities in DM prevention, treatment, and health outcomes.