Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources: Results of the Measuring Economic Insecurity in Diabetes Study | Journal Scan

Study Questions:

What is the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources?

Methods:

Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at one academic primary care clinic, two community health centers, and one specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (ages ≥21 years) with diabetes mellitus (response rate, 62.3%). The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol [LDL-C] level, >100 mg/dl; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits).

Results:

Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least one material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97; 95% confidence interval [CI], 1.58-2.47) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19; 95% CI, 1.05-1.36), but not increased ED/inpatient visits (IRR, 1.00; 95% CI, 0.51-1.97). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91; 95% CI, 1.35-2.70) and increased ED/inpatient visits (IRR, 1.68; 95% CI, 1.21-2.34), but not outpatient visits (IRR, 1.07; 95% CI, 0.95-1.21). Housing instability (IRR, 1.31; 95% CI, 1.14-1.51) and energy insecurity (IRR, 1.12; 95% CI, 1.00-1.25) were associated with increased outpatient visits, but not with diabetes control (OR, 1.10; 95% CI, 0.60-2.02 and OR, 1.27; 95% CI, 0.96-1.69, respectively) or with ED/inpatient visits (IRR, 1.49; 95% CI, 0.81-2.73 and IRR, 1.31; 95% CI, 0.80-2.13, respectively). An increasing number of insecurities was associated with poor diabetes control (OR for each additional need, 1.39; 95% CI, 1.18-1.63) and increased use of health care resources (IRR for outpatient visits, 1.09; 95% CI, 1.03-1.15; IRR for ED/inpatient visits, 1.22; 95% CI, 0.99-1.51).

Conclusions:

The authors concluded that material need insecurities were common among patients with diabetes mellitus and had varying, but generally adverse associations with diabetes control and the use of health care resources.

Perspective:

This study reports that material need insecurities are common despite high levels of overall health insurance and prescription drug coverage. Although all material need insecurities had some generally moderate association with poor clinical diabetes control or the increased use of health care resources, no single insecurity was associated with all outcomes. For example, food insecurity was strongly and independently associated with glycemic control and outpatient visits, whereas cost-related medication underuse was associated with poor control of glycemia, LDL-C levels, and blood pressure, along with increased ED/inpatient visits. In addition to their individual associations, an increasing number of material need insecurities was associated with worse clinical outcomes and use of health care resources. It seems that food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus.

Clinical Topics: Dyslipidemia, Lipid Metabolism, Nonstatins

Keywords: Diabetes Mellitus, Blood Pressure, Cholesterol, LDL, Community Health Centers, Emergency Service, Hospital, Food Supply, Hemoglobin A, Glycosylated, Hospitalization, Housing, Insurance, Health, Massachusetts


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