Author ORCID Identifier
https://orcid.org/0000-0002-7336-1355
Date Available
1-19-2026
Year of Publication
2026
Document Type
Doctoral Dissertation
Degree Name
Doctor of Public Health (DrPH)
College
Public Health
Department/School/Program
Health Services Research
Faculty
Min-Woong Sohn
Faculty
Brandi Frisby
Abstract
The American Diabetes Association (ADA) recommends that patients with diabetes adopt 7 preventive care measures to improve their health outcomes. The recommendations are to check their blood glucose levels daily, undergo biennial hemoglobin A1c tests, undergo dilated eye exams once every 2 years, engage in regular physical activity, check their feet daily, have annual feet examinations performed by a clinician, and receive diabetes self-management education services (DSMES). Marital status has been found to be associated with positive health outcomes; thus, it is ideal to evaluate if there is an association between marital status and diabetes preventive care. The ADA also recommends statins for patients with diabetes to reduce their risk of developing cardiovascular-related complications, and statins also hold promise for reducing the risk of having non-traumatic lower extremity amputations among patients with diabetes. Despite ADA recommendations, the uptake of statins is less than 60% and significant disparities may exist in certain populations.
Study one evaluated the association between marital status and the use of diabetes preventive care using the Behavioral Risk Factor Surveillance System data from 2019-2021, collected from the US 50 States and territories. Seven measures of preventive care were evaluated. They include dilated eye exams every two years to screen for retinopathy, engagement in leisure-time physical activity, annual foot exams performed by a healthcare professional, daily self-checks of the feet, two or more HbA1c tests annually, daily self-monitoring of blood glucose, and diabetes self-management education. Responses from 160,192 patients who answered “yes” to having diabetes were included in the study. Compared to unmarried respondents, married respondents have 1.23-1.29 times higher odds of using the recommended preventive care. The average treatment effect shows that being married was associated with a 2.7-5.6% increased use of diabetes preventive care. These findings show that marriage may be a predictor of the use of preventive care among patients with diabetes
Statins are recommended for patients with diabetes who are 40-75 years old to reduce their risk of developing cardiovascular disease, the leading cause of death among patients with diabetes. Despite this, statin uptake is low, as observed in less than 60% of recommended users. There are limited studies on statin use among the Medicaid population, and considering that this population has a higher prevalence of diabetes, an evaluation of the trends and disparities of statin use was warranted. Study two sought to identify and track trends and disparities in statin use among Kentucky Medicaid enrollees using claims data from 2010-2019. Patients who were 40-64 years old were included in the study, and prescription drug records were used to identify statin users. Significant disparities by age, race/ethnicity, and the Medicaid delivery system were observed. Statin use increased over time for all age groups except for those who were 40-44 years. A graded relationship was observed among the age groups. Males had about 15% lower uptake of statins compared to females in 2010 (OR = 0.85; 95% CI, 0.81 – 0.90; p < 0.001), but by 2019, the trend had reversed with males having higher odds of uptake (OR = 1.16; 95% CI, 1.12 – 1.21; p < 0.001). While there were disparities by race/ethnicity, the gap in use narrowed during the study period. By 2019, the odds of statin use among the Non-Hispanic Black population were 6% lower than the Non-Hispanic White population (OR = 0.94; 95% CI, 0.88 – 1.00; p = 0.053). Statin use increased over time for all managed care organizations but declined for fee-for-service users (from 20% in 2010 to ~6% in 2012 and stayed below 10% throughout the study period). Sensitivity analysis showed that the findings were robust to different definitions of statins (possession of ≥ 60-day supply and ≥ 180-day supply).
Non-traumatic lower extremity amputations are a complication associated with diabetes, and prior studies show promising results on the association between statins and a decline in NLEAs. Knowing this, study three examined the association between statin use and the occurrence of NLEAs, hypothesizing that statin use would be associated with reduced odds of occurrence of NLEAs. Kentucky Medicaid data from the Kentucky Cabinet for Health and Family Services for the years 2018-2022 were used for this study. The study population consisted of 7,870 patients, and a nested case-control design matching on age, race/ethnicity, and sex was used. Statin use was defined as use for at least 180 days. Using a conditional logistic regression, interaction terms for statin use and foot ulcers were included in the model, considering that foot ulcers are a direct risk factor for NLEAs among patients with diabetes. The highest frequency of NLEAs was found among the 50-59-year-old age group. Overall, patients who used statins for 180 days or more were 37% less likely to have NLEAs (OR = 0.63, 95% CI = 0.46 - 0.87, p = 0.025). Tests of interaction showed that foot ulcers modify the association between NLEAs and statins (p for interaction < .0001). Compared to patients who did not have foot ulcers and did not use statins, patients who used statins and had no foot ulcers were approximately 50% less likely to have NLEAs. (OR = 0.50, 95% CI = 0.28 - 0.88, p = 0.016) However, compared to patients who did not use statins and had foot ulcers, patients who used statins and had foot ulcers were 33% less likely to have NLEAs (OR = 0.69, 95% CI = 0.48 - 1.01, p = 0.059). These findings shed light on the importance for clinicians to consider marital status when advising patients, as well as the need for them to prescribe and encourage statin use among the population with diabetes. It also calls for significant interventions at the community level to educate patients on the benefits of statins.
Digital Object Identifier (DOI)
https://doi.org/10.13023/etd.2025.627
Recommended Citation
Oikeh, Aiemere O., "Three essays on disparities and outcomes among patients with diabetes" (2026). Theses and Dissertations--Health Services Research (HSR). 2.
https://uknowledge.uky.edu/hsr_etds/2
