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Utilizing Connected Health Applications in Diabetes Care: Implications for Public Health and Policy in the U.S

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Utilizing Connected Health Applications in Diabetes Care: Implications for Public Health and Policy in the U.S UTILIZING CONNECTED HEALTH APPLICATIONS IN DIABETES CARE: IMPLICATIONS FOR PUBLIC HEALTH AND POLICY IN THE U.S. A dissertation submitted to the Kent State University College of Public Health in partial fulfillment of the requirements for the degree of Doctor of Philosophy by Heather Mikulski May 2021 A dissertation written by Heather Mikulski B.A., Kent State University, 2008 M.P.P., University of Erfurt, Willy Brandt School of Public Policy, 2010 Ph.D., Kent State University, 2021 Approved by Jonathan VanGeest, Ph.D., Chair, Doctoral Dissertation Committee Sonia Alemagno, Ph.D., Member, Doctoral Dissertation Committee John Hoornbeek, Ph.D., Member, Doctoral Dissertation Committee Kerstin Rebrin, M.D., Ph.D., Member, Doctoral Dissertation Committee Accepted by Sonia Alemagno, Ph.D., Dean, College of Public Health Jeffrey S. Hallam, Ph.D., Associate Dean, College of Public Health ii TABLE OF CONTENTS LIST OF ACCRONYMS .............................................................................................................. vii ACKNOWLEDGEMENTS ............................................................................................................ x LIST OF TABLES ......................................................................................................................... xi LIST OF FIGURES ..................................................................................................................... xiii Chapter 1: Introduction ................................................................................................................... 1 Background ................................................................................................................................. 1 Public Health Significance .......................................................................................................... 3 Structure ...................................................................................................................................... 7 Chapter 2: Literature Review .......................................................................................................... 9 Epidemiologic Data ..................................................................................................................... 9 Testing of Glucose for Diagnosis & Screening ......................................................................... 12 Diabetes Types .......................................................................................................................... 15 Complications............................................................................................................................ 23 Diabetes Care Model ................................................................................................................. 28 Technology ................................................................................................................................ 33 Economic Impact....................................................................................................................... 44 Policy Landscape....................................................................................................................... 49 Food and Drug Administration ................................................................................................. 50 Medicare .................................................................................................................................... 53 iii Medicaid .................................................................................................................................... 54 Veteran’s Administration .......................................................................................................... 56 Commercial Payer Policy .......................................................................................................... 57 Overarching Policy Organizations ............................................................................................ 58 Reimbursement.......................................................................................................................... 59 Chapter 3: Methodology ............................................................................................................... 66 Methods ..................................................................................................................................... 66 Measures.................................................................................................................................... 72 XClinical System Marvin ...................................................................................................... 72 Diabetes Treatment Satisfaction Questionnaire .................................................................... 73 Blood Glucose Values ............................................................................................................... 74 Data Analysis ............................................................................................................................ 75 Chapter 4: Results ......................................................................................................................... 79 Hypothesis 1 – HbA1c Impact .................................................................................................. 84 Hypothesis Two – Diabetes Treatment Satisfaction ................................................................. 93 Sub-Group Determinations ..................................................................................................... 101 Sub-Group by Age – Change in HbA1c .............................................................................. 101 Sub-Group by Gender – Differences in HbA1c .................................................................. 107 Sub-Group by Race – Change in HbA1c ............................................................................. 109 iv Sub-Group by Diabetes Type – Change in HbA1c ............................................................. 112 Sub-group Age Group – DTSQc Score ............................................................................... 114 Sub-Group by Gender – DTSQc Score ............................................................................... 119 Sub-Group by Race – DTSQc ............................................................................................. 121 Sub-Group by Diabetes Type – DTSQc .............................................................................. 123 Summary Statistics .................................................................................................................. 125 Chapter 5: Discussion ................................................................................................................. 127 Summary Glycemic Control.................................................................................................... 127 Summary Treatment Satisfaction ............................................................................................ 128 Summary Subgroup Analyses ................................................................................................. 129 Population Health Implications ............................................................................................... 129 Other Examples of Technology in Diabetes Care ................................................................... 130 Policy Implications .................................................................................................................. 132 Evidence Review ..................................................................................................................... 138 Addressing Care Gaps – Quality of Care ................................................................................ 141 Addressing Care Gaps – Access to Care ................................................................................. 145 Addressing Care Gaps – Patient Adherence ........................................................................... 148 Connected Health Applications Outside of Diabetes .............................................................. 150 Summary ................................................................................................................................. 151 v Strengths .................................................................................................................................. 152 Limitations .............................................................................................................................. 154 Conclusions ............................................................................................................................. 155 References ................................................................................................................................... 157 vi LIST OF ACCRONYMS ACA .......................................Affordable Care Act ACO .......................................Accountable Care Organization AACE .....................................Association of Clinical Endocrinologists ADA .......................................American Diabetes Association ADCES ..................................Association of Diabetes Care & Education Specialists ALS ........................................Amyotrophic Lateral Sclerosis AMA ......................................American Medical Association AHRQ ....................................Agency
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