Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System.

BACKGROUND: Sub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level. OBJECTIVE: To examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health). DESIGN: This study used clinical, administrative, and prescription dispensing data (January-December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship. PARTICIPANTS: Patients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18-75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073). MAIN MEASURES: Our measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value. KEY RESULTS: In the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (ß = 0.31, p = < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (ß = - 0.18, p = < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (ß = 0.31, p = < 0.001). CONCLUSIONS: The findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers.

The Diabetes Health Plan and Healthcare Utilization Among Beneficiaries with Low Incomes.

BACKGROUND: The socioeconomic status (SES) gradient in hospital and emergency room utilization among adults with type 2 diabetes (T2DM) is partially driven by cost-related non-adherence. OBJECTIVE: To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific health plan incorporating value-based insurance design principles on healthcare utilization among low-income adults with T2DM. DESIGN: To examine the impact of the DHP on healthcare utilization, we employed a difference-in-differences (DID) study design with a propensity-matched comparison group. We modeled count and dichotomous outcomes using Poisson and logit models, respectively. PARTICIPANTS: Cohort of adults (18-64) with T2DM, with an annual household income <$ 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least 2 years between 2009 and 2014. INTERVENTIONS: The DHP reduces or eliminates out-of-pocket costs for disease management visits, diabetes-related medicines, and diabetes self-monitoring supplies. The DHP also provides access to diabetes-specific telephone case management as well as other online resources. MAIN MEASURES: Number of disease management visits (N = 1732), any emergency room utilization (N = 1758), and any hospitalization (N = 1733), within the year. KEY RESULTS: DID models predicting disease management visits suggested that DHP-exposed beneficiaries had 1.7 fewer in-person disease management visits per year (- 1.70 [95% CI: - 2.19, - 1.20], p < 0.001), on average, than comparison beneficiaries. Models for emergency room (0.00 [95% CI: - 0.06, 0.06], p = 0.966) and hospital utilization (- 0.03 [95% CI: - 0.08, - 0.01], p = 0.164) did not demonstrate statistically significant changes associated with DHP exposure. CONCLUSIONS: While no relationship between DHP exposure and high-cost utilization was observed in the short term, fewer in-person disease management visits were observed. Future studies are needed to determine the clinical implications of these findings.

Evidence for the Role of State-Level Economic Policy in HIV Risk Reduction: State Earned Income Tax Credit Generosity and HIV Risk Behavior Among Single Mothers.

We investigated the impact of State-level Earned Income Tax Credit (SEITC) generosity on HIV risk behavior among single mothers with low education. We merged individual-level data from the Behavioral Risk Factor Surveillance System (2002-2018) with state-level data from the University of Kentucky Center for Poverty Research and conducted a multi-state, multi-year difference-in-differences (DID) analysis. We found that a refundable SEITC ≥ 10% of the Federal Earned Income Tax Credit was associated with 21% relative risk reduction in reporting any high-risk behavior for HIV in the last year, relative to no SEITC. We also found that a 10-percentage point increase in SEITC generosity was associated with 38% relative risk reduction in reporting any high-risk HIV behavior in the last year. SEITC policy may be an important strategy to reduce the burden of HIV infections among women with low socioeconomic status, particularly single mothers.

RESUMEN: Investigamos el impacto de la generosidad del Crédito Federal Tributario por Ingreso de Trabajo a nivel estatal (SEITC) sobre el comportamiento de riesgo al VIH entre madres solteras con baja educación. Unimos los datos a nivel individual del Sistema de Vigilancia a Factores de Riesgo de Comportamiento (2002­2018) con los datos a nivel estatal del Centro de Investigación de la Pobreza de la Universidad de Kentucky, y conducimos un análisis de diferencia-en-diferencia (DID) multi-estado y multi-año. Encontramos que un reembolso SEITC ≥ 10% del Crédito Federal Tributario por Ingreso de Trabajo estaba asociado con una reducción relativa de riesgo de 21% en reportar cualquier comportamiento de riesgo alto al VIH en el último año, relativo a ningún SEITC. También encontramos que un aumento de punto porcentual de 10 en la generosidad SEITC estaba asociado con una reducción relativa de riesgo de 38% en reportar cualquier comportamiento de riesgo alto al VIH en el último año. La póliza SEITC puede ser una estrategia importante para reducir la carga de infecciones al VIH entre mujeres con bajo nivel socioeconómico, particularmente entre madres solteras.

Exploring the relationship between self-employment and women's cardiovascular health.

BACKGROUND: Compared with wage and salary work, self-employment has been linked to more favorable cardiovascular health outcomes within the general population. Women comprise a significant proportion of the self-employed workforce and are disproportionately affected by cardiovascular disease. Self-employed women represent a unique population in that their cardiovascular health outcomes may be related to gender-specific advantages of non-traditional employment. To date, no studies have comprehensively explored the association between self-employment and risk factors for cardiovascular disease among women. METHODS: We conducted a weighted cross-sectional analysis using data from the University of Michigan Health and Retirement Study (HRS). Our study sample consisted of 4624 working women (employed for wages and self-employed) enrolled in the 2016 HRS cohort. Multivariable linear and logistic regression were used to examine the relationship between self-employment and several self-reported physical and mental health risk factors for cardiovascular disease, controlling for healthcare access. RESULTS: Among working women, self-employment was associated with a 34% decrease in the odds of reporting obesity, a 43% decrease in the odds of reporting hypertension, a 30% decrease in the odds of reporting diabetes, and a 68% increase in the odds of reporting participation in at least twice-weekly physical activity (p < 0.05). BMI for self-employed women was on average 1.79 units lower than it was for women working for wages (p < 0.01). CONCLUSIONS: Employment structure may have important implications for cardiovascular health among women, and future studies should explore the causal relationship between self-employment and cardiovascular health outcomes in this population. TRIAL REGISTRATION: Not applicable.

The impact of Dual Eligible Special Need Plan regulations on healthcare utilization.

BACKGROUND: To determine if requiring Dual Eligible Special Need Plans (D-SNPs) to receive approval from the National Committee of Quality Assurance and contract with state Medicaid agencies impacts healthcare utilization. METHODS: We use a Multiple Interrupted Time Series to examine the association of D-SNP regulations with dichotomized measures of emergency room (ER) and hospital utilization. Our treatment group is elderly D-SNP enrollees. Our comparison group is near-elderly (ages 60-64) beneficiaries enrolled in Medicaid Managed Care plans (N = 360,405). We use segmented regression models to estimate changes in the time-trend and slope of the outcomes associated with D-SNP regulations, during the post-implementation (2012-2015) period, relative to the pre-implementation (2010-2011) period. Models include a treatment-status indicator, a monthly time-trend, indicators and splines for the post-period and the interactions between these variables. We conduct the following sensitivity analyses: (1) Re-estimating models stratified by state (2) Estimating models including interactions of D-SNP implementation variables with comorbidity count to assess for differential D-SNP regulation effects across comorbidity level. (3) Re-estimating the models stratifying by race/ethnicity and (4) Including a transition period (2012-2013) in the model. RESULTS: We do not find any statistically significant changes in ER or hospital utilization associated with D-SNP regulation implementation in the broad D-SNP population or among specific racial/ethnic groups; however, we do find a reduction in hospitalizations associated with D-SNP regulations in New Jersey (DD level = - 3.37%; p = 0.02)/(DD slope = - 0.23%; p = 0.01) and among individuals with higher, relative to lower levels of co-morbidity (DDD slope = - 0.06%; p = 0.01). CONCLUSIONS: These findings suggest that the impact of D-SNP regulations varies by state. Additionally, D-SNP regulations may be particularly effective in reducing hospital utilization among beneficiaries with high levels of co-morbidity.

An Effectiveness Evaluation of a Primary Care-Embedded Clinical Pharmacist-Led Intervention Among Blacks with Diabetes.

BACKGROUND: Black individuals with type 2 diabetes suffer disproportionate morbidity and mortality relative to whites with type 2 diabetes, irrespective of health insurance coverage. OBJECTIVE: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on cardiovascular risk factor control among blacks with type 2 diabetes in a large healthcare system. DESIGN: We used data extracted from the electronic health records (EHR) system and a difference-in-differences study design with a propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure (SBP) among black patients with type 2 diabetes, relative to usual care. PARTICIPANTS: Individuals with type 2 diabetes identified as either black or African American in the EHR that were ≥ 18 years of age that had the following observations during the study window (03/02/2013-12/31/18: (1) HbA1C ≥ 8%, at least once, anywhere between 365 days before and 14 days after the UCMyRx visit and a follow-up HbA1c measure within 120 to 365 days after the visit and/or (2) SBP ≥ 140 mmHg at least once between 365 days before and 14 days after the UCMyRx visit that had a follow-up SBP measure within 120 to 450 days after the visit. INTERVENTION: UCMyRx pharmacists review labs and vital signs, perform medication reconciliation, use a standardized survey to assess barriers to medication adherence, and develop tailored interventions to improve medication adherence. MAIN MEASURES: Change in HbA1c and change in SBP from before to after the first UCMyRx visit. KEY RESULTS: Having at least one visit with a UCMyRx clinical pharmacist was associated with a significant reduction in HbA1c (- 0.4%, p value = .01); however, there was no significant impact on SBP (- .051 mmHg, p value = 0.74). CONCLUSIONS: The UCMyRx intervention is a useful strategy for improving HbA1c control among blacks with type 2 diabetes.

Examining the association of changes in minimum wage with health across race/ethnicity and gender in the United States.

BACKGROUND: The minimum wage creates both winners (through wage increases) and-potentially-losers (through job losses). Research on the health effects of minimum wage policies has been sparse, particularly across gender and among racial/ethnic minorities. We test the impact of minimum wage increases on health outcomes, health behaviors and access to healthcare across gender and race/ethnicity. METHODS: Using 1993-2014 data from the Behavioral Risk Factor Surveillance System, variables for access to healthcare (insurance coverage, missed care due to cost), health behavior (exercise, fruit, vegetable and alcohol consumption) and health outcomes (self-reported fair/poor health, hypertension, poor physical health days, poor mental health days, unhealthy days) were regressed on the product of the ratio of the 1-year lagged minimum wage to the state median wage and the national median wage, using Linear Probability Models and Poisson Regression Models for dichotomous and count outcomes, respectively. Regressions (total population, gender-stratified, race/ethnicity stratified (white, black, Latino), gender/race/ethnicity stratified and total population with interaction terms for race/ethnicity/gender) controlled for state-level ecologic variables, individual-level demographics and fixed-effects (state and year). Results were adjusted for complex survey design and Bonferroni corrections were applied to p-values such that the level of statistical significance for a given outcome category was 0.05 divided by the number of outcomes in that category. RESULTS: Minimum wage increases were positively associated with access to care among white men, black women and Latino women but negatively associated with access to care among white women and black men. With respect to dietary quality, minimum wage increases were associated with improvements, mixed results and negative impacts among white, Latino and black men, respectively. With respect to health outcomes, minimum wage increases were associated with positive, negative and mixed impacts among white women, white men and Latino men, respectively. CONCLUSIONS: While there is enthusiasm for minimum wage increases in the public health community, such increases may have to be paired with deliberate strategies to protect workers that might be vulnerable to economic dislocation. Such strategies may include more robust unemployment insurance or increased access to job training for displaced workers.

Making Strides Toward Health Equity: The Experiences of Public Health Departments.

OBJECTIVES: We explored the definition of health equity being used by public health departments and the extent of engagement of public health departments in activities to improve health equity, as well as facilitators and barriers to this work. DESIGN: We conducted 25 semistructured qualitative interviews with lead public health officials (n = 20) and their designees (n = 5). All interviews were transcribed and thematically analyzed. SETTING: We conducted interviews with respondents from local public health departments in the United States (April 2017-June 2017). PARTICIPANTS: Respondents were from local or state public health departments that were members of the Big Cities Health Coalition, accredited or both. RESULTS: Many departments were using a definition of health equity that emphasized an equal opportunity to improve health for all, with a special emphasis on socially disadvantaged populations. Improving health equity was a high priority for most departments and targeting the social determinants of health was viewed as the optimal approach for improving health equity. Having the capacity to frame issues of health equity in ways that resonated with sectors outside of public health was seen as a particularly valuable skill for facilitating cross-sector collaborations and promoting work to improve health equity. Barriers to engaging in work to improve health equity included lack of flexible and sustainable funding sources as well as limited training and guidance on how to conduct this type of work. CONCLUSIONS: Work to improve health equity among public health departments can be fostered and strengthened by building capacity among them to do more targeted framing of health equity issues and by providing more flexible and sustained funding sources. In addition, supporting peer networks that will allow for the exchange of resources, ideas, and best practices will likely build capacity among public health departments to effectively do this work.

Pharmacist-Led Diabetes Control Intervention and Health Outcomes in Hispanic Patients With Diabetes.

Importance: Among patients with type 2 diabetes (T2D), Hispanic individuals are more likely than non-Hispanic White individuals to develop diabetes-related complications. Objective: To examine the association of a pharmacist-led intervention (UCMyRx) with hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) among Hispanic patients with T2D. Design, Setting, and Participants: This quality improvement study used electronic health record data and a difference-in-differences study design to evaluate the association of UCMyRx exposure with changes in HbA1c concentration and SBP among Hispanic patients with T2D, relative to usual care, at University of California, Los Angeles primary care clinics between February and April of 2023. The study population included patients with an International Classification of Diseases, Ninth Revision/International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis of T2D, self-reporting Hispanic ethnicity, age 18 years or older, with 1 or more visits with a UCMyRx pharmacist (treatment) or 2 or more visits, 2 or more years apart, during the study window (comparison). Additionally, patients had to have the following observations during the study window (March 2, 2013-December 31, 2018): (1) a HbA1c 8% or higher, anywhere between 365 days before and 14 days after the index date (date of the first UCMyRx visit or a randomly generated index date) and a follow-up HbA1c measure within 120 to 365 days after the index date (n = 396) and/or (2) a SBP 140 mm Hg or higher between 365 days before and 14 days after the index date, and a follow-up SBP measure within 120 to 450 days after the index date (n = 795). Exposure: Pharmacists review laboratory results/vital signs, perform medication reconciliation, and develop personally tailored interventions to address adherence barriers and increase guideline-concordant care. Main Outcomes and Measures: Pre- to post-index date changes in HbA1c and SBP. Results: Of the 931 unique patients with T2D analyzed, the mean (SD) age was 64 (14.1) years, and 552 (59.3%) were female. In adjusted analyses, having 1 or more UCMyRx visits was associated with a reduction in HbA1c concentration (ß = -0.46%; 95% CI, -0.84% to -0.07%) but no change in SBP (ß = -1.71 mm Hg; 95% CI, -4.00 to 0.58 mm Hg). Conclusions and Relevance: In this quality improvement study of UCMyRx among Hispanic patients with T2D, a negative association was observed between UCMyRx exposure and HbA1c concentration but not SBP. Pharmacist-led intervention may be a strategy for improving outcomes among Hispanic patients with T2D.

The diabetes health plan and medication adherence among individuals with low incomes.

OBJECTIVE: To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM). DATA SOURCES AND STUDY SETTING: Cohort of adults (18-64) with T2DM, an annual household income

An Effectiveness Study of a Primary Care-embedded Clinical Pharmacist-Led Intervention Among Patients With Diabetes and Medicaid Coverage.

OBJECTIVE: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. METHODS: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. RESULTS: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). CONCLUSIONS: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.

Exploring the Relationship Between Self-Employment and Health Among Blacks.

Purpose: There is some evidence that self-employment may improve measures of cardiovascular and general health among the general population; however, no studies have examined this relationship among Non-Hispanic Blacks (NHBs). Studying the health implications of self-employment among NHBs is important because of the disparities that persist in both cardiovascular health and self-employment rates between NHBs and other racial/ethnic subgroups. Methods: A pooled cross-sectional analysis of data from the Behavioral Risk Factor Surveillance System (2000 to 2014) was used to explore the association between self-employment and the following self-reported outcomes: "no exercise," fruit consumption, vegetable consumption, days of alcohol consumption, fair or poor health, hypertension, poor mental health days, and poor physical health days among the total population of NHBs and across gender/income subgroups. Results: We find favorable associations between self-employment and several measures of cardiovascular health (increased fruit and vegetable consumption, reduced reports of "no exercise," and reduced reports of hypertension) and positive associations between self-employment, poor mental health days, and days of alcohol consumption among the total population. The nature of these associations varies across gender/income subgroup. Conclusions: Given the disparities between racial/ethnic subgroups with respect to adverse cardiovascular outcomes and the well-documented roles of exercise and blood pressure control in limiting cardiovascular disease, it is important to probe the relationship between self-employment and health among NHBs further.

Evidentiary needs of US public health departments with a mission to advance equity and health: a qualitative analysis.

OBJECTIVES: We sought the perspectives of lead public health officials working to improve health equity in the USA regarding the drivers of scientific evidence use, the supply of scientific evidence and the gap between their evidentiary needs and the available scientific evidence. DESIGN: We conducted 25 semistructured qualitative interviews (April 2017 to June 2017) with lead public health officials and their designees. All interviews were transcribed and thematically analysed. SETTING: Public health departments from all geographical regions in the USA. PARTICIPANTS: Participants included lead public health officials (20) and their designees (5) from public health departments that were either accredited or part of the Big Cities Health Coalition. RESULTS: Many respondents were using scientific evidence in the context of grant writing. Professional organisations and government agencies, rather than specific researchers or research journals, were the primary sources of scientific evidence. Respondents wanted to see more locally tailored cost-effectiveness research and often desired to participate in the planning phase of research projects. In addition to the scientific content recommendations, respondents felt the usefulness of scientific evidence could be improved by simplifying it and framing it for diverse audiences including elected officials and community stakeholders. CONCLUSIONS: Respondents are eager to use scientific evidence but also need to have it designed and packaged in ways that meet their needs.