Author

Amber Moore

Date

March 2009

Document Type

Thesis

Degree Name

M.P.H.

Department

Dept. of Public Health and Preventive Medicine

Institution

Oregon Health & Science University

Abstract

Background: Diabetes is one of the most clinically burdensome and financially costly chronic diseases in the United States. To date, medical management of this condition has been largely unsuccessful; the majority of people with diabetes have poorly controlled disease, resulting in avoidable complications and cost. Additionally, individuals with public insurance may be disproportionately affected by the complications of diabetes compared to individuals with private insurance coverage. The chronic illness management (CIM) model of care has been shown to improve clinical outcomes for people with diabetes compared to a traditional general internal medicine (GIM) model of care. However, it is currently unknown if the CIM model provides equal benefit to publically and privately insured individuals. Objectives: This goal of this study was two-fold. First, the relationship between insurance status (public or private) and blood glucose (measured by HbA1c) was examined. Second, insurance status was studied to determine if individuals with one type of insurance derive greater benefit from the CIM model compared to the GIM model of care. Methods: This study utilized a database derived from clinical records of 662 patients with diabetes receiving care in a CIM specialty clinic or a GIM practice within an academic medical center between July 2005 and January 2008. A retrospective cohort design was used to examine the effects of insurance status and care model on HbA1c outcomes over 335 days of follow-up, on average. Both logistic and linear regression analyses were conducted to examine the dependent variable as both a continuous and categorical outcome, adjusting for potential confounders. An interaction term was utilized in the model to determine if the care model influences the relationship between insurance type and HbA1c outcomes. Results: There were no independent or joint associations between median HbA1c during follow-up and insurance type or model of care. The odds of ever achieving glucose control during the follow up period was 62% less in privately insured individuals compared to publically insured individuals (p <0.001), however this relationship was not modified by the model of care delivery (p for interaction=0.229). Conclusion: The publically insured group had better glucose control than the privately insured group. There was no difference in HbA1c outcomes between the two care models, and individuals with public and private insurance derived equal benefit from both care models.

Identifier

doi:10.6083/M4MS3QQK

School

School of Medicine

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