How economic insecurity impacts diabetes control among patients

Increased access to health insurance offered by the Patient Protection and Affordable Care Act may not improve diabetes control among low-income patients because of social determinants of health, which are outside the scope of medical practice, such as difficulty paying for food, medications, housing or utilities (material need insecurities), according to the study background.

Seth A. Berkowitz, M.D., M.P.H., of Massachusetts General Hospital, Boston, and coauthors sought to determine the association between material need insecurities and diabetes control and the use of health care resources. Their study of 411 patients included data from June 2012 through October 2013 collected at a primary care clinic, two community health centers and a specialty treatment center for diabetes in Massachusetts.

The study found that, overall, 19.1 percent of patients reported food insecurity; 27.6 percent cited cost-related medication underuse; 10.7 percent had housing instability; 14.1 percent had trouble paying for utilities (energy insecurity); and 39.1 percent of patients reported at least one material need insecurity. Poor diabetes control (as measured by factors including hemoglobin A1c, low-density lipoprotein cholesterol level or blood pressure) was seen in 46 percent of patients.

According to the study results, food insecurity was associated with greater odds of poor diabetes control and increased outpatient visits but not increased emergency department(ED)/inpatient visits. Cost-related medication underuse was associated with poor diabetes control and increased ED/inpatient visits but not outpatient visits. Housing instability and energy (utilities) insecurity were associated with increased outpatient visits but not with diabetes control or with ED/outpatient visits. Having an increasing number of economic insecurities was associated with poor diabetes control and increased health care use.

"Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities. In particular, food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus," the study concludes.