Receipt of Diabetes Preventive Care Among Safety Net Patients Associated with Differing Levels of Insurance Coverage

Rachel Gold; Jennifer E. DeVoe; Patti J. McIntire; Jon E. Puro; Susan L. Chauvie; Amit R. Shah

doi:10.3122/jabfm.2012.01.110142

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Table 1.

Demographics of Adults with Diabetes in OCHIN Clinics, Overall and Stratified by Insurance Coverage Group (2005–2007)

	Entire Study Population	Continuously Insured	Partially Insured	Continuously Uninsured
Total	3384 (100)	1764 (52.1)	711 (21.0)	909 (26.9)
Age (years) on January 1, 2005^*
19–35	356 (10.5)	83 (4.7)	102 (14.4)	171 (18.8)
36–50	1034 (30.6)	410 (23.2)	241 (33.9)	383 (42.1)
51–65	1363 (40.3)	751 (42.6)	293 (41.2)	319 (35.1)
≥65	631 (18.7)	520 (29.5)	75 (10.6)	36 (4.0)
Sex^{^†}
Female	1942 (57.4)	1051 (59.6)	422 (59.4)	469 (51.6)
Male	1442 (42.6)	713 (40.4)	289 (40.7)	440 (48.4)
Language^*
English	1843 (54.5)	1093 (62.0)	480 (67.5)	270 (29.7)
Spanish	1079 (31.9)	316 (17.9)	177 (24.9)	586 (64.5)
Other	357 (10.6)	297 (16.8)	34 (4.8)	26 (2.9)
Missing	105 (3.1)	58 (3.3)	20 (2.8)	27 (3.0)
Race/ethnicity^*
White	1637 (48.4)	1001 (56.8)	398 (56.0)	238 (26.2)
Hispanic	1201 (35.5)	385 (21.8)	209 (29.4)	607 (66.8)
Other	450 (13.0)	311 (17.6)	82 (11.5)	57 (6.3)
Missing	96 (2.8)	67 (3.8)	22 (3.1)	7 (0.8)
Mean Federal Poverty Level (%)^*^{^‡}
0–99	2532 (74.8)	1356 (76.9)	526 (74.0)	650 (71.5)
≥100	712 (21.0)	304 (17.2)	152 (21.4)	256 (28.2)
Missing	140 (4.1)	104 (5.9)	33 (4.6)	3 (0.3)

Demographic and preventive services data from OCHIN safety net clinic networked electronic health record dataset; insurance coverage confirmed through individual links to Medicaid enrollment data (2005–2007). OCHIN originally stood for the Oregon Community Health Information Network; it was renamed just “OCHIN” as clinics in states other than Oregon became OCHIN members.
Values provided as n (%). Demographic data from OCHIN Inc. safety net clinic networked electronic health record dataset; insurance coverage confirmed through individual links to Medicaid enrollment data (2005–2007).
↵* P < .0001 (χ²) for an association between insurance continuity and demographic characteristics.
† P < .001 (χ²) for an association between insurance continuity and demographic characteristics.
‡ Mean federal poverty level (FPL) was calculated as the average over all visits in the study period. Values >1000% were considered missing; this was <2% of the visits, and the 5.7% with missing FPL information include these outliers.

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Table 2.

Receipt of Diabetes Preventive Care Services Among Adults With Diabetes in OCHIN Clinics, by Continuity of Insurance Coverage, 2005–2007

	Study Population (n [%])	Low-Density Lipoprotein Screen (%)		Influenza Vaccination (%)		HbA1c Screen (%)		Microalbumin Screen (%)
	Study Population (n [%])	≥1^*	≥3^*	≥1^*	≥3^*	≥1^*	≥3^*	≥1^*	≥3^*
Continuously insured	1764 (52.1)	83.1	47.6	75.9	25.3	94.1	72.3	61.2	18.9
Continuously uninsured	909 (26.9)	68.4	27.2	62.4	8.3	91.0	57.5	57.8	14.1
Partially insured	711 (21.0)	64.4	31.7	65.7	14.5	85.0	57.4	51.6	12.7
Percent of the study period with coverage^{^†}
1% to 19%	53 (7.5)	69.8	26.4	60.4	13.2	90.6	64.2	64.2	9.4
20% to 39%	91 (12.8)	60.4	28.6	56.0	8.8	82.4	53.9	46.2	14.3
40% to 59%	65 (9.1)	70.8	27.7	56.9	12.3	90.8	53.9	63.1	18.5
60% to 79%	188 (26.4)	63.8	35.6	69.7	14.9	87.8	59.0	52.1	13.3
80% to 99%	314 (44.2)	63.7	31.9	68.8	16.6	81.9	57.0	48.4	11.2

Demographic and preventive services data from OCHIN safety net clinic networked electronic health record dataset; insurance coverage confirmed through individual links to Medicaid enrollment data (2005–2007). OCHIN originally stood for the Oregon Community Health Information Network; it was renamed just “OCHIN” as clinics in states other than Oregon became OCHIN members.
↵* χ²; P < .0001, comparing percent of those continuously insured, continuously uninsured, and partially insured who received the service ≥1 times versus never or ≥3 times versus <3 times, as indicated.
↵† Among the 711 partially insured patients.
HbA1c, glycohemoglobin.

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Table 3.

Logistic Regression Analyses of Associations Between Insurance Continuity and Receipt of Preventive Services ≥3 Times Among Adults with Diabetes in OCHIN Clinics (n = 3,384)

	≥3 Low-Density Lipoprotein Screens		≥3 Influenza Vaccinations		≥3 HbA1c Screens		≥3 Microalbumin Screens
	Univariate	Adjusted^*	Univariate	Adjusted^*	Univariate	Adjusted^*	Univariate	Adjusted^*
Sex
Female	1.04 (0.90–1.21)	1.02 (0.88–1.18)	1.13 (0.94–1.36)	1.10 (0.91–1.34)	1.14 (0.98–1.32)	1.12 (0.96–1.30)	1.20 (0.99–1.45)	1.21 (0.99–1.47)
Male	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Age (years)
19–35	0.52 (0.39–0.69)	0.86 (0.63–1.16)	0.34 (0.22–0.50)	0.62 (0.40–0.95)	0.74 (0.56–0.98)	1.19 (0.88–1.62)	0.74 (0.51–1.07)	1.04 (0.70–1.55)
36–50	0.67 (0.54–0.83)	0.98 (0.78–1.23)	0.51 (0.39–0.66)	0.82 (0.62–1.09)	0.69 (0.55–0.86)	1.02 (0.80–1.29)	0.91 (0.69–1.19)	1.16 (0.86–1.55)
51–65	0.86 (0.71–1.06)	1.10 (0.89–1.36)	0.82 (0.65–1.04)	1.13 (0.89–1.45)	0.87 (0.70–1.07)	1.16 (0.92–1.45)	0.88 (0.68–1.14)	1.01 (0.77–1.32)
≥65	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Race/ethnicity
Hispanic	0.80 (0.68–0.94)	1.07 (0.90–1.27)	1.02 (0.83–1.25)	1.63 (1.31–2.04)	1.06 (0.91–1.25)	1.37 (1.15–1.64)	0.72 (0.57–0.89)	0.75 (0.59–0.95)
Other	1.48 (1.20–1.83)	1.41 (1.13–1.75)	1.63 (1.26–2.10)	1.52 (1.17–1.97)	1.92 (1.51–2.46)	1.87 (1.46–2.40)	1.69 (1.32–2.18)	1.68 (1.30–2.17)
White	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Federal poverty level
0% to 99%	1.07 (0.90–1.27)	0.97 (0.81–1.16)	0.97 (0.78–1.21)	0.84 (0.67–1.05)	1.07 (0.90–1.27)	0.97 (0.81–1.16)	1.02 (0.81–1.28)	0.97 (0.77–1.22)
≥100%	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)
Insurance coverage
Partially insured	0.51 (0.42–0.62)	0.53 (0.43–0.64)	0.49 (0.38–0.62)	0.51 (0.39–0.65)	0.50 (0.42–0.61)	0.50 (0.41–0.60)	0.62 (0.47–0.80)	0.64 (0.49–0.84)
Continuously uninsured	0.41 (0.35–0.49)	0.43 (0.35–0.53)	0.27 (0.21–0.35)	0.25 (0.19–0.34)	0.50 (0.42–0.59)	0.46 (0.37–0.56)	0.68 (0.55–0.86)	0.82 (0.63–1.06)
Continuously insured	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)

Demographic and preventive services data from OCHIN safety net clinic networked electronic health record dataset; insurance coverage confirmed through individual links to Medicaid enrollment data (2005–2007). OCHIN originally stood for the Oregon Community Health Information Network; it was renamed just “OCHIN” as clinics in states other than Oregon became OCHIN members.
Values provided as odds ratios (95% CIs). OCHIN originally stood for the Oregon Community Health Information Network; it was renamed just ‘OCHIN' as clinics in states other than Oregon became OCHIN members.
Bold indicates statistical significance at p < 0.05.
↵* Adjusted for all variables shown.
HbA1c, glycohemoglobin.

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Table 4.

Logistic Regression Analyses of Associations Between Insurance Continuity and Receipt of Preventive Services Among Adults with Diabetes in OCHIN Clinics (n = 711 with partial coverage, n = 1764 with full coverage)

Percent of Time Insured	≥3 Low-Density Lipoprotein Screen		≥3 Influenza Vaccination		≥3 HbA1c Screen		≥3 Microalbumin Screen
Percent of Time Insured	Univariate	Adjusted^*	Univariate	Adjusted^*	Univariate	Adjusted^*	Univariate	Adjusted^*
1% to 19%	0.40 (0.21–0.74)	0.43 (0.23–0.82)	0.46 (0.20–1.02)	0.51 (0.23–1.16)	0.66 (0.37–1.17)	0.65 (0.36–1.17)	0.44 (0.17–1.11)	0.46 (0.18–1.20)
20% to 39%	0.44 (0.27–0.71)	0.48 (0.30–0.79)	0.30 (0.14–0.62)	0.32 (0.15–0.68)	0.42 (0.27–0.65)	0.41 (0.26–0.65)	0.73 (0.40–1.33)	0.84 (0.45–1.57)
40% to 59%	0.39 (0.22–0.70)	0.40 (0.22–0.71)	0.39 (0.18–0.86)	0.37 (0.17–0.83)	0.41 (0.24–0.68)	0.40 (0.24–0.67)	1.03 (0.54–1.95)	1.18 (0.61–2.27)
60% to 79%	0.64 (0.46–0.88)	0.68 (0.49–0.94)	0.51 (0.33–0.79)	0.52 (0.34–0.81)	0.58 (0.42–0.80)	0.59 (0.42–0.82)	0.65 (0.42–1.02)	0.74 (0.47–1.17)
80% to 99%	0.51 (0.39–0.67)	0.53 (0.40–0.70)	0.56 (0.40–0.79)	0.58 (0.41–0.82)	0.48 (0.37–0.63)	0.49 (0.37–0.64)	0.51 (0.34–0.76)	0.55 (0.36–0.82)
100%	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)	1.00 (ref)

↵* Adjusted for sex, age, race/ethnicity, and Federal Poverty Level.
OCHIN originally stood for the Oregon Community Health Information Network; it was renamed just “OCHIN” as clinics in states other than Oregon became OCHIN members.
Bold indicates statistical significance.
HbA1c, glycohemoglobin.