DIABETES AND HYPERTENSION OUTCOMES IN REPEATED-CROSS-SECTION EVALUATION IN MEXICO

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1 THE IMPACT OF SOCIAL HEALTH INSURANCE ON DIABETES AND HYPERTENSION OUTCOMES IN OLDER ADULTS: AN INSTRUMENTAL-VARIABLES REPEATED-CROSS-SECTION EVALUATION IN MEXICO Maricruz Rivera-Hernández, Vincent Mor, Omar Galárraga Brown University School of Public Health Center for Gerontology and Healthcare Research National Research Service Award 2T32HS

Rivera-Hernández, Vincent Mor, Omar Galárraga Brown University School of Public Health

2 Introduction Hypertension &di diabetes in Mexico Amongthetop10leadingcauses top of death in Mexico Hypertension 31.6% of the adult population has hypertension (INSP, 2012). Costs of hypertension totaled about USD $6,536 million (INSP, 2012). Diabetes 6.2 million adults (9.2%) have been diagnosed with diabetes( INSP, 2012a). Direct costs were estimated to be USD $3.4 billion, and indirect costs were estimated to be USD $177 million (Barquera et al. 2013). Picture courtesy of Razi Marysol Machay

2 million adults (9.2%) have been diagnosed with diabetes( INSP, 2012a). Direct costs were estimated to be USD $3.

3 Introduction (Continued) Healthcare system in Mexico IMSS Private sector employees ISSSTE Government workers SP Excluded from IMSS/ISSSTE

4 Introduction (Continued) Impact of Seguro Popular SP enrollees with hypertension have higher probability of using antihypertensive treatment with control of blood pressure (OR: 1.35) (Bleich et al., 2007). SP enrollees with diabetes have more access to blood glucose tests (by 9.5 pp), insulin (3.13 more per week), and dbetter HbA1c 7 (by 5.6 pp) (Sosa-Rubi, Galarraga & Lopez-Ridaura, 2009).

5 Objective The main objective of this paper is to examine the impact of SP on diabetes and hypertension treatment and care, focusing on the older adult population (age>50). Based on the literature (Bleich et al., 2007; Sosa-Rubi et al., 2009), we hypothesized that SP would influence self-management and health care utilization for people with diabetes and hypertension.

Based on the literature (Bleich et al., 2007; Sosa-Rubi et al.

6 Methods ENSANUT Mexican Census Mexican Department of Health information (2000,2005-6, & (2000, 2005, 2012) &2010) (2000, 2005, & 2009) Individual id characteristics Data about state s uninsured Information about states Diabetes: There were 731, 868 and 1,416 older adults 50 years and over. Hypertension: There were 1,339, 1,696 and 2,272 older adults over 50 years people and people enrolled din SP. human and physical resources (total number of doctors, number of nurses, and number of hospitals).

868 and 1,416 older adults 50 years and over.

7 Methods (Continued) Dependent variables Diabetes treatment & care (binary) Treatment with insulin or other oral agents Diet Exercise Hypertension treatment & care (binary) Use of antihypertensive medication Diet Exercise

other oral agents Diet Exercise Hypertension treatment

8 Methods (Continued) Independent variables Insurance (enrolled in SP) Sex, age, education, ethnicity, BMI, time since disease diagnosis, i and family assets State fixed effect and physical resources (total number of doctors, number of nurses, and number of hospitals) to control unobservable regional factors that influence diabetes and/or hypertension treatment and care

physical resources (total number of doctors, number of nurses, and number of hospitals) to

9 Methods (Continued) Instrumental variables (IV) 1. Number of years SP has been incorporated in the adult s state of residence at the time of the survey 2. Participation rates in SP in the adult respondent s area of residence at the locality level in 2005 and 2010 Given that t the process of SP accreditation ti at the locality level was driven by several independent factors, there was temporal and geographic variation that helps identify enrollment into SP, independently of diabetes & hyperthension outcomes.

Participation rates in SP in the adult respondent s area of residence at the locality level in 2005 and 2010 Given that t the

10 Results Diabetes care and treatment outcomes for older adults (age>50) enrolled in SP or uninsured in Mexico Year 2000 Year 2006 Year 2012 Uninsured Uninsured SP Uninsured SP Treatment n = 573 n = 232 n = 82 n = 290 n = 782 Yes 520 (90.75) 214 (92.24) 82 (98.80)* 240 (82.76) 706 (90.28)* Diet n=566 n=235 n=84 n=290 n=782 Yes 121 (21.38) 52 (22.13) 21 (25.00) 56 (19.31) 169 (21.61) Exercise n = 466 n = 199 n = 72 n = 290 n = 782 Yes 21 (4.51) 16 (8.04) 9 (12.50) 23 (7.93) 65 (8.31)

75) 214 (92.24) 82 (98.80)* 240 (82.76) 706 (90.28)* Diet n=566 n=235 n=84 n=290 n=782 Yes 121 (21.38) 52 (22.13) 21 (25.

11 Results (Continued) Hypertension care and treatment outcomes for older adults (age>50) enrolled in SP or uninsured in Mexico Year 2000 Year 2006 Year 2012 Uninsured Uninsured SP Uninsured SP Treatment t n = 874 n = 503 n = 182 n = 455 n = 1208 Yes 657 (75.17) 358 (71.17) 136 (74.73) 372( 81.76) 1015 (84.02) Diet n = 953 n = 412 n = 162 n = 372 n = 1015 Yes 78 (8.18) 83 (20.15) 28 (17.28) 59 (15.86) 151 (14.88) Exercise n = 875 n =374 n = 144 n = 372 n = 1015 Yes 0(0) 45 (12.03) 10 (6.94) 32 (8.60) 72 (7.09)

(75.17) 358 (71.17) 136 (74.73) 372( 81.76) 1015 (84.02) Diet n = 953 n = 412 n = 162 n = 372 n = 1015 Yes 78 (8.18) 83 (20.

12 Results (Continued) IV evaluation of the effect of SP on diabetes and hypertension treatment and care : 2SLS second stage results N Coefficient 95% CI Diabetes Treatment [-.1095,.0291] Diet [-.1061,.0845] Exercise [-.0154,.1153] Hypertension Treatment [.0220,.1693]* Diet [.0744,.2034]*** Exercise [.0337,.1224]***

1095,.0291] Diet 1959 -.0108 [-.1061,.0845] Exercise 1811.0499 [-.0154,.

13 Discussion SP has significantly impacted hypertension treatment & care Use of medication by 9.5 percentage points Use of diet tby 13.8 percentage points Practice of exercise by 7.8 percentage points Consistent results with Bleich et al. (2007) SP has not impacted diabetes treatment & care Different results than Sosa-Rubi et al. (2009)

8 percentage points Practice of exercise by 7.

14 Discussion (Continued) Using ENSANUT 2012 other studies have also found poor self-management behaviors and care among people with diabetes (e.g.,rivera- Hernandez, 2014). Having health insurance does not necessarily improve health care behaviors (Ross and Mirowsky 2000), specially for older people with diabetes. Insurance is only a first step toward better health h care. People need to take responsibility in managing their health (Karolewicz, 2014).

Having health insurance does not necessarily improve health care behaviors (Ross and Mirowsky 2000), specially

15 Discussion (Continued) Older adults may not have the knowledge, or lack the motivation and skills, to engage g in diabetes self-care practices (Barquera et al. 2013). Current challenges in the Mexican healthcare system included shortfalls in pharmacological treatment, lack of specialized care and physicians, poor infrastructure, medical equipment and laboratory facilities (INSP,2010).

Current challenges in the Mexican healthcare system included shortfalls in pharmacological

16 Discussion (Continued) Limitations The findings reflect medium-term effects of SP on self-management activities. Explore long-term effects of SP on care Self-reported outcomes Biological i l outcomes Repeated-cross sections Longitudinal ldata

Explore long-term effects of SP on care Self-reported

17 Discussion (Continued) Policy-makers and practitioners need to better address the burden of diabetes in Mexico among older populations. Having SP-insurance may be only the beginning in achieving good outcomes: better quality of care is needed to improve quality of life and decrease mortality among older adults with diabetes.

Having SP-insurance may be only the beginning in achieving good outcomes: better

18 Thank you! Questions? edu

Example of Type 2 Diabetes

Why Health Insurance Reform? The Example of Type 2 Diabetes Millard, Ann V., Margaret A. Graham, Nelda Mier, and Isidore Flores Diane Ariza, Moderator Health Issues Confronting Latinos/as Latino/a Communities