Document Type

Capstone Experience

Graduation Date

5-2023

Degree Name

Master of Public Health

Department

Biostatistics

First Committee Member

Gleb R Haynatzki, PhD, DSc

Second Committee Member

Abraham D Mengist, PhD

Third Committee Member

Kate Grafel, MPH, CPhT

Fourth Committee Member

Andjela Drincic, MD

Abstract

Background: Ensuring that individuals with type 2 diabetes properly manage their chronic condition is a nation-wide challenge, even among individuals who have health insurance coverage and access to the treatment they need. There exist several literature sources that suggest various factors that may influence an individual’s lack of self-management of type 2 diabetes. This study investigated some of these factors by determining whether various demographic, social determinant, and health factors were associated with three self-management measures among individuals with type 2 diabetes.

Methods: The self-management measures of interest included (i) whether the annual recommended two primary care visits were attended (ii) whether one annual eye exam was conducted, and (iii) hemoglobin A1C (HbA1C) test results. Data on 19,258 insured individuals with Type 2 diabetes was obtained from Blue Cross and Blue Shield of Nebraska (BCBSNE) and contains measures from three individual years: 2019, 2020, and 2021. Data was analyzed using mixed effects binary logistic regression models with repeated measures for the first two outcomes and a mixed effects cumulative logistic regression model with repeated measures for the third outcome. Analyses also investigated whether the associations found changed over the course of the three review periods as a result of the COVID-19 pandemic beginning in March of 2020.

Results: With all other predictors adjusted for, older insured individuals with Type 2 Diabetes were more likely than younger individuals to adhere to the recommended two primary care visits and one annual eye exam, as well as achieve a lower HbA1C level. Females were more likely to receive an annual eye exam and achieve a lower HbA1C level, while males were more likely to attend two annual primary care visits. Individuals who identified as Eastern European, African American, or any other ethnic group other than Hispanic were more likely to attend two annual primary care visits than individuals who identified as Western European, while Western European individuals were more likely to achieve a lower HbA1C level. The low-income group was less likely than both the middle-income and high-income groups to receive an annual eye exam. The odds of receiving an annual eye exam were higher with each increasing OOP expense range, while the odds of attending two annual primary care visits were lower with each increasing OOP expense range. Individuals who lived in urban areas were more likely to achieve a lower HbA1C level than those who lived in rural areas. Nonsmokers were more likely than smokers to attend two annual primary care visits and receive an annual eye exam. Those who did not have an obesity or high cholesterol diagnosis were more likely to attend two annual primary care visits. Individuals who did not have an obesity or hypertension diagnosis were more likely to achieve a lower HbA1C level. Possibly as a result of the onset of the COVID-19 pandemic, individuals who had high blood pressure were more likely to attend two annual primary care visits in 2019 than in 2020 and both individuals who lived in rural areas and individuals who lived in urban areas were more likely to receive an annual eye exam in 2019 than in either 2020 or 2021.

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