Date on Master's Thesis/Doctoral Dissertation

8-2016

Document Type

Doctoral Dissertation

Degree Name

Ph. D.

Department

Health Management and Systems Sciences

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Esterhay, Robert

Committee Co-Chair (if applicable)

Little, Bert

Committee Member

Brock, Guy

Committee Member

LaJoie, Scott

Author's Keywords

diabetes; onset; remission; lifestyle

Abstract

Background: Type 2 diabetes mellitus (T2DM) is a progressive disease condition. As the disease progresses the function of beta (β) cells (cells which regulate insulin) decline, thereby increasing the circulating blood glucose levels. If left unmanaged the disease progresses from onset to development of T2DM related complications and eventually death. When managed, in certain individuals, T2DM onset can be prevented and/or slowed down and in certain T2DM individuals, remission is observed. There are some known modifiable risk factors such as diet and physical activities that are associated with the speed and direction of progression, but much is still unknown. In order to develop effective intervention and management programs, it is first important to understand the factors that predict speed and direction of T2DM progression. Purpose: This dissertation evaluated T2DM disease progression with three key objectives: a) evaluate factors that predict T2DM onset; b) evaluate rate of T2DM “remission” and, c) evaluate factors that predict T2DM “remission” in Medicare patients 65 years and older who did not undergo bariatric surgery. Methods: A retrospective cohort analysis of a Medicare Advantage health plan was conducted using administrative data. An individual was identified as T2DM if they had: ≥ 2 medical claims for T2DM coded 250.xx excluding type 1 diabetes; or ≥ 2 pharmacy claims related to T2DM; or ≥ 2 combined medical claims, pharmacy claims for T2DM in 12 months. A T2DM individual was in “remission” if they had no T2DM related claims for more than 12 months continuously. This is different from the standard American Diabetes Association definition of remission which includes HbA1c values and hence is represented in quotation (as “remission”). 89,390 individuals were evaluated for T2DM onset and 10,059 T2DM individuals were evaluated for T2DM “remission” over a period of 8 years from 2008 to 2015. Cox proportional hazards was used to identify significant variables associated with T2DM onset and “remission.” Results: The factors that were significantly associated with T2DM onset were: male gender; non-white ethnicity (African American, Hispanics); statin use; hypertension; hyperlipidemia; heart failure; ulcer of lower limbs; atherosclerosis; other retinopathy; angina pectoris; blindness and low vision; absence of other chronic ischemic heart disease (IHD) (pConclusions:In line with previously published studies, the study presented here also found that hyperlipidemia, hypertension, gender and race are significantly associated with T2DM onset. In addition to these known factors, this study identified additional factors associated with T2DM onset such as: statin use; hypertension; hyperlipidemia; heart failure; ulcer of lower limbs; atherosclerosis; other retinopathy; angina pectoris; blindness and low vision and absence of other chronic ischemic heart disease. This study found that in Medicare T2DM patients 65 years and older “remission” does occur without bariatric surgery. This study verified known factors such as absence of dyslipidemia and race to be associated with T2DM “remission.” In addition to these known factors this study found that no statin use; low diabetes complications severity index score (DCSI); no hypertension; no neuropathy; no retinopathy; presence of other chronic ischemic heart disease (IHD) and female gender were significantly associated with T2DM “remission.” These findings could be used for the development of T2DM related disease intervention and management programs. The DCSI score of T2DM individuals could be used to help stratify them based on T2DM severity for design and individualized, targeted outreach. Lastly, in this study hypertension, hyperlipidemia, statins use were associated with T2DM onset and T2DM “remission.” Since these factors are also associated with metabolic disease, their mutual relation needs to be evaluated further, upon availability of laboratory and physician notes data. Metabolic disease is a known predictor for T2DM onset and future studies might find that metabolic disease might also be a predictor for T2DM “remission.”

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