title: Racial differences in impact of coverage on diabetes self-monitoring in a health maintenance organization.
abstract: BACKGROUND
  Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care.
  
  
  OBJECTIVE
  We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes.
  
  
  METHODS
  Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy.
  
  
  METHODS
  The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy.
  
  
  RESULTS
  Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients.
  
  
  CONCLUSIONS
  The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence.
authors.affiliation: Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts 02215, USA. cmah@fas.harvard.edu
authors.forename: Connie A
authors.initials: CA
authors.lastname: Mah
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Soumerai
authors.forename: Alyce S
authors.initials: AS
authors.lastname: Adams
authors.forename: Dennis
authors.initials: D
authors.lastname: Ross-Degnan
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D015190:Blood Glucose Self-Monitoring / Q000191:economics / Q000295:instrumentation / Q000706:statistics & numerical data; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000097:blood* / Q000188:drug therapy / Q000191:economics*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006279:Health Maintenance Organizations / Q000706:statistics & numerical data*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D010349:Patient Compliance / Q000208:ethnology; D044465:White People / Q000706:statistics & numerical data*
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin