ACE-D: Assess insurance Coverage Expansion on Diabetes complications

项目摘要 截至2017年，美国有超过3000万人患有糖尿病（DM）。DM有许多急性 和慢性并发症（例如，蜂窝织炎、尿路感染、心绞痛和缺血性心脏病等）。 糖尿病患者需要获得医疗保健（例如，处方药，糖尿病眼科检查，实验室 监测）来控制、管理DM，并预防DM相关并发症，这对患者来说是一项具有挑战性的任务 没有持续的健康保险。患者保护和平价医疗法案（ACA） 通过医疗补助资格扩大（在选择扩大的州）提高医疗保险费率， 全国个人健康保险市场。我们研究了早期接受医疗补助的影响， 扩大（2014年）低收入人群中DM患者获得和提供医疗保健的机会 并发现在扩大医疗补助计划的州，医疗保险的吸收率高于那些没有扩大医疗补助计划的州， 以及增加获得预防保健和改善糖尿病控制的机会。随着所需资源的增加， 护理，据推测，ACA医疗补助扩张将减少DM相关并发症的发生率; 然而，这一假设尚未得到正式检验。此外，除了保险范围外，还有 可能影响DM的其他个人和社区水平的健康社会决定因素（SDH）数量- 相关的健康结果。据我们所知，没有研究调查如何邻里或个人 这些特征影响ACA对DM相关并发症的影响。我们将利用电子健康 记录来自社区卫生中心（CHC）的国家ADVANCE临床研究网络的数据， 来自22个医疗补助扩展州的801个CHC的患者水平数据（n= 177，125例成年DM患者）， 460例CHC处于7种非扩张状态（n= 104，849例成人DM患者）。我们还将把这些EHR数据 死亡率和社区SDH数据。该项目的目的是：1）评估长期影响 ACA医疗补助计划对糖尿病相关并发症的扩展。2)比较DM相关并发症， 稳定的健康保险与不稳定的健康保险相比;以及，3）了解 个人和社区层面的SDH对ACA医疗补助扩张和DM相关 并发症我们的研究结果将是至关重要的通知目前正在作出的决定，对未来的 ACA和其他医疗改革正在提出，可能会影响数百万糖尿病患者。

Project Summary As of 2017, over 30 million people in the United States live with diabetes mellitus (DM). DM has many acute and chronic complications (e.g., cellulitis, urinary tract infection, angina and ischemic heart disease, etc.). Patients with DM need access to healthcare (e.g., prescription medications, diabetic eye exams, laboratory monitoring) to control, manage DM, and prevent DM-related complications, a challenging task for patients without continuous health insurance. The Patient Protection and Affordable Care Act (ACA) substantially increased health insurance rates through Medicaid eligibility expansions (in states that chose to expand) and nationwide individual health insurance marketplaces. We studied the impact of the early uptake of Medicaid expansion (2014) on access to and delivery of healthcare among patients with DM in low-income populations and found a greater uptake of health insurance in states that expanded Medicaid relative to those that did not, as well as increased access to preventive care and improved DM control. With increased access to needed care, it is hypothesized that ACA Medicaid expansions will reduce the incidence of DM-related complications; however, this hypothesis has not yet been formally tested. Further, beyond insurance coverage, there are a number of other individual- and community-level social determinants of health (SDH) that likely impact DM- related health outcomes. To our knowledge, no study has investigated how neighborhood or individual characteristics influence the effects of the ACA on DM-related complications. We will leverage electronic health record data from the national ADVANCE clinical research network of community health centers (CHCs) which has patient-level data from 801 CHCs in 22 Medicaid expansion states (n=177,125 adult patients with DM) and 460 CHCs in 7 non-expansion states (n=104,849 adult patients with DM). We will also link these EHR data with mortality and community-level SDH data. The aims of this project are to: 1) evaluate the long-term impact of ACA Medicaid expansions on DM-related complications. 2) compare DM-related complications for those with stable health insurance versus those with unstable coverage; and, 3) understand the moderating effect of individual- and community-level SDH on the relationship between ACA Medicaid expansions and DM-related complications. Our findings will be critical to informing current decisions being made regarding the future of the ACA and additional healthcare reforms being brought forth that could impact millions of patients living with DM.