ACE-D: Assess insurance Coverage Expansion on Diabetes complications

项目摘要 截至2017年，美国有超过3000万糖尿病患者。糖尿病有很多急性 和慢性并发症(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)控制、管理和预防糖尿病相关并发症，这对患者来说是一项具有挑战性的任务 没有持续的医疗保险。患者保护和平价医疗法案(ACA)实质上 通过扩大医疗补助资格(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 关于低收入人群中糖尿病患者获得和提供医疗保健的扩展(2014) 研究发现，与没有扩大医疗补助的州相比，扩大医疗补助的州对医疗保险的接受度更高， 以及更多获得预防性护理和改善糖尿病控制的机会。增加了对所需资源的访问 护理，这是假设，ACA医疗补助扩大将减少糖尿病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的其他个人和社区层面的社会健康决定因素(SDH)的数量- 相关的健康结果。据我们所知，还没有研究调查邻居或个人 ACA的性质影响ACA对DM相关并发症的疗效。我们将利用电子健康 来自全国社区卫生中心(CHCs)高级临床研究网络的记录数据 有来自22个医疗补助扩展州(n=177,125名成年糖尿病患者)的801个CHC的患者级别数据 7个非扩张状态的460个CHC(n=104,849例成人DM患者)。我们还将链接这些电子病历数据 死亡率和社区层面的SDH数据。本项目的目的是：1)评估长期影响 ACA医疗补助计划在糖尿病相关并发症方面的扩展。2)比较以下患者的糖尿病相关并发症 拥有稳定医疗保险的人与覆盖范围不稳定的人；以及，3)了解 个人和社区层面的SDH关于ACA医疗补助扩展与DM相关关系的研究 并发症。我们的发现将是至关重要的，为目前正在做出的关于未来的决定 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.