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Chronic Disease Management Complicated by Economic Insecurity

By Jennifer Bresnick

Economic insecurity has a significant effect on chronic disease management and diabetes control, a new study finds.

- Proper chronic disease management for diabetes is significantly more difficult for patients facing economic insecurity that makes it a hardship to secure basic needs, finds a new study in JAMA Internal Medicine this month. Patients with multiple economic concerns, including buying food, paying utility bills, and housing instability, were more likely to also report poor control of their diabetes while accessing more outpatient healthcare services.

medication adherence and chronic disease management

A research team led by Seth A. Berkowitz, MD, MPH, from Massachusetts General Hospital surveyed 411 patients to better understand the relationship between chronic disease management, healthcare utilization, and economic status. They used standard measures of blood glucose levels, cholesterol levels, and blood pressure control to define how well a patient had their diabetes in hand. As a secondary measure, the team also looked at emergency department use, inpatient hospitalizations, and outpatient care use to determine the patient’s level of contact with the healthcare system.

Many of the patients reported more than one economic hardship, including 19.1% experiencing food insecurity, 10.7% reporting housing instability, 14.1% with energy insecurity, and 39.1% stating they could not afford at least one basic material need. More than a quarter admitted that they were non-adherent to their medications due to cost. Among the same patient population, 46% were found to have poor diabetes control.

Food insecurity was associated most often with a lack of diabetes control, and was also associated with greater use of outpatient care, though not of emergency department visits or hospitalizations. Medication non-adherence due to high costs, however, was linked to a higher number of ED visits, but not to more outpatient consults. The more insecurities reported per patient, the more likely he or she was to experience poor diabetes control, the study found.

Previous studies have also flagged the link between socioeconomic status and the impact of diabetes and other chronic diseases. A recent report found that low-income residents in California, particularly black and Spanish-speaking patients, were nearly twice as likely as other groups to require limb amputations due to complications from diabetes, while internet users searching Google are most likely to request information on diabetes, diet, blood pressure control, and free medications if they live in low-income areas.

As accountable care and outcomes-based reimbursement become significant drivers for population health management, the study may help providers target chronic disease management resources to patients with specific socioeconomic needs.

“Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care,” the study says. “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.”

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