Impact of Emerging Health Insurance Designs on Diabetes Complications

描述（由申请人提供）：糖尿病并发症，如视网膜病变、肾衰竭、截肢、中风和心肌梗死，对糖尿病患者的健康有重大影响，并导致高死亡率。为了延缓并发症的进展、控制症状和预防死亡，需要一系列的医疗护理，包括高敏度的医生就诊、先进的诊断测试和侵入性治疗。一种快速增长的医疗保险形式--高免赔额保险--大大增加了患者对此类服务的自付费用。高免赔额健康计划的家庭必须每年支付高达12,000美元，才能开始更全面的覆盖。高水平的费用分摊旨在鼓励更有效和更高质量的护理，但也可能减少获得治疗并发症和拯救生命的服务的机会。了解高免赔额健康计划如何影响糖尿病患者的微血管和大血管结局至关重要。次优的接入可能会减少并发症的检测，加速疾病进展，并增加死亡率。该提案旨在评估高免赔额健康计划对微血管和大血管糖尿病并发症的影响，以及对影响这些并发症的护理的影响，包括医生就诊，诊断测试和主要治疗。我们对医生就诊的测量将包括门诊和急诊科就诊，具体诊断可能与糖尿病并发症有关，我们将急诊科就诊分为高或低严重程度。我们将检查的诊断测试包括视网膜成像，肾活检，外周血管造影，高级脑成像和心导管插入术。我们将进一步评估冠心病检查是否不适当地用于筛查糖尿病患者。我们对大血管并发症的综合治疗措施包括下肢旁路移植术、溶栓和冠状动脉支架植入术。为了评估健康结果，我们将研究微血管并发症的综合指标，评估晚期视网膜病变的治疗和透析或肾移植的需要。我们的复合大血管结局将包括下肢截肢、心肌梗死、卒中和死亡。这项研究将包括一个为期15年的71，000名糖尿病患者的滚动样本，这些患者的雇主要求从传统的健康计划转向高免赔额的健康计划。我们将使用雇主和成员级别的倾向得分匹配，以尽量减少选择偏差。本研究将采用强准实验设计，包括中断时间序列与比较序列和Kaplan-Meier生存曲线，以检查关注的结局。该项目将是第一个在全国范围内审查这些研究问题的项目。

DESCRIPTION (provided by applicant): Complications of diabetes such as retinopathy, renal failure, amputation, stroke, and myocardial infarction have a major impact on the wellbeing of patients with diabetes and cause high rates of death. To delay progression of complications, control symptoms, and prevent mortality, a spectrum of medical care is needed including high acuity physician visits, advanced diagnostic tests, and invasive therapy. A rapidly growing form of health coverage - high-deductible insurance - substantially increases patients' out-of-pocket costs for such services. Families in high-deductible health plans must pay up to $12,000 per year before more comprehensive coverage begins. High cost-sharing levels are intended to encourage more efficient and higher quality care but could also reduce access to services that treat complications and save lives. It is essential to understand how high-deductible health plans affect micro- and macro vascular outcomes in diabetes. Suboptimal access could reduce detection of complications, accelerate disease progression, and increase deaths. This proposal seeks to assess the impact of high-deductible health plans on micro- and macro vascular diabetes complications and on the care that affects them, including physician visits, diagnostic testing, and major therapies. Our measure of physician visits will comprise outpatient and emergency department visits with specific diagnoses potentially related to diabetes complications, and we will classify emergency department visits as high or lower severity. The diagnostic tests we will examine include retinal imaging, renal biopsy, peripheral angiography, advanced brain imaging, and cardiac catheterization. We will further assess whether tests for coronary heart disease are used inappropriately to screen patients with diabetes. Our composite measure of therapy for macro vascular complications will include lower extremity bypass grafting, thrombolysis, and coronary artery stenting. To assess health outcomes, we will examine a composite measure of micro vascular complications assessing treatment for advanced retinopathy and need for dialysis or renal transplant. Our composite macro vascular outcome will include lower extremity amputation, myocardial infarction, stroke, and death. This study will include a 15-year rolling sample of 71,000 diabetes patients whose employers mandated a switch from traditional to high-deductible health plans. We will use employer- and member-level propensity score matching to minimize selection bias. The study will employ strong quasi-experimental designs including interrupted time-series with comparison series and Kaplan-Meier survival curves to examine outcomes of interest. This project will be the first to examine these research questions on a national scale.