Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management

Berkowitz, Seth A.; Hulberg, Amy Catherine; Standish, Sara; Reznor, Gally; Atlas, Steven J.

doi:10.1001/jamainternmed.2016.7691

Cited by 180 publications

(192 citation statements)

References 38 publications

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“…35 We lacked data on Medicare and Medicaid participants, for whom the effects of monthly pay cycles may be larger or smaller (as they may qualify for further supports not available to marginally fail to qualify). Notably, due to recent health reforms, large portions of low-income Americans are now privately insured, but privately-insured patients are often less likely than Medicaid participants to be recognized as being at risk for food insecurity, 36,37 and thus clinicians may not recognize the need to adjust treatment strategies for periods of limited food access. Indeed, recent literature suggests that extra-marginal populations who barely miss the Medicaid or SNAP cut-points would be of most concern because they spend the most money on essential expenditures like rent and food, and face food insecurity without assistance that can mitigate the risks of hypoglycemia.…”

Section: Discussionmentioning

confidence: 99%

The Monthly Cycle of Hypoglycemia

2017

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Background Multi-payer initiatives have sought to address social determinants of health, such as food insecurity, by linking primary care patients to social services. It remains unclear whether such social determinants contribute to avoidable short-term healthcare costs. Objectives We sought to quantify costs and mitigating factors for the increased risk of hypoglycemia at the end of each month among low-income Americans, a phenomenon related to exhaustion of food budgets. Research design We used claims data on 595,770 commercially-insured American adults aged 19 through 64 years old from 2004 through 2015 to estimate the risks and costs of emergency room visits and inpatient hospitalizations for hypoglycemia during the last week of each month versus prior weeks. Results While persons with household incomes greater than the national median did not experience a monthly cycle of hypoglycemia, those with incomes less than the national median had an odds ratio of 1.07 (95% CI: 1.02, 1.12; p = 0.005) for emergency room visits or inpatient hospitalizations for hypoglycemia during the last week of each month, compared with earlier weeks. The risk of end-of-the-month hypoglycemia was mitigated to statistical insignificance during a period of increased federal nutrition program benefits from 2009 through 2013. Eliminating the monthly cycle of hypoglycemia among commercially-insured nonelderly adults would be expected to avert $54.1 million per year (95% CI: $0.8, $204.0) in emergency department and inpatient hospitalization costs. Conclusions Addressing the end-of-the-month increase in hypoglycemia risk among lower-income populations may avert substantial costs from emergency department visits and inpatient hospitalizations.

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Section: Discussionmentioning

confidence: 99%

The Monthly Cycle of Hypoglycemia

2017

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“…While only in its nascence, initiatives such as the Centers for Medicare & Medicaid Accountable Health Communities 45 and community linkage programs such as Health Leads 50 and Kaiser Permanente’s Total Health 47 may provide some insight into best practices for translating this ideal into practice. The data gleaned from projects such as these will be vital in understanding whether transforming care to focus on the ‘whole patient’ can produce substantial improvements in quality and health from the perspectives of patients, partners, practices, and payers.…”

Section: Discussionmentioning

confidence: 99%

Addressing the Social Needs of Hypertensive Patients

Schoenthaler

Knafl

Fiscella

et al. 2017

Circ: Cardiovascular Quality and Outcomes

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Background Poor medication adherence is a pervasive problem in patients with hypertension. Despite research documenting an association between patient-provider communication and medication adherence, there is no empirical data on how the informational and relational aspects of communication affect patient’s actual medication-taking behaviors. The aim of this study was to evaluate the impact of patient-provider communication on medication adherence among a sample of primary care providers and their Black and White hypertensive patients. Methods and Results Cohort study of 92 hypertensive patients and 27 providers in three safety-net primary care practices in New York City. Patient-provider encounters were audiotaped at baseline and coded using the Medical Interaction Process System. Medication adherence data were collected continuously over the 3-month study with an electronic monitoring device. The majority of patients were Black, 58% women, and most were seeing the same provider for at least one year. Approximately half of providers were White (56%), 67% women, and have been in practice for an average of 5.8 years. Fifty-eight percent of patients exhibited poor adherence to prescribed antihypertensive medications. Three categories of patient-provider communication predicted poor medication adherence: lower patient-centeredness (OR: 3.08, 95CI: 1.04–9.12), less discussion about patients’ social-demographic circumstances [living situation, relationship with partner] (OR: 6.03, 95CI:2.15–17) and about their antihypertensive medications (OR: 6.48, 95CI:1.83–23.0). The effect of having less discussion about patients’ social-demographic circumstances on medication adherence was heightened in Black patients (OR: 8.01, 95CI:2.80–22.9). Conclusions The odds of poor medication adherence are greater when patient-provider interactions are low in patient-centeredness and do not address patients’ social-demographic circumstances or their medication regimen.

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“…However, to our knowledge, this trial’s enrollment rates were higher than those in many published sociobehavioral intervention studies. 5,49 …”

Section: Limitationsmentioning

confidence: 99%

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities

et al. 2018

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IMPORTANCE Addressing the social determinants of health has been difficult for health systems to operationalize. OBJECTIVE To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. DESIGN, SETTING, AND PARTICIPANTS This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. INTERVENTION Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. MAIN OUTCOMES AND MEASURES The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. RESULTS Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, −3.1 days; 95% CI, −6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, −0.3; 95% CI, −0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, −0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, −0.17; P = .04). CONCLUSIONS AND RELEVANCE A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health.

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Addressing Unmet Basic Resource Needs as Part of Chronic Cardiometabolic Disease Management

Cited by 180 publications

References 38 publications

The Monthly Cycle of Hypoglycemia

The Monthly Cycle of Hypoglycemia

Addressing the Social Needs of Hypertensive Patients

Effect of Community Health Worker Support on Clinical Outcomes of Low-Income Patients Across Primary Care Facilities

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