Impact of Social Determinants of Health on Patients with Complex Diabetes Who Are Served by National Safety-Net Health Centers

Abstract

Objective: Recent research demonstrates an increased need to understand the contribution of social determinants of health (SDHs) in shaping an individual's health status and outcomes. We studied patients with diabetes in safety-net centers and evaluated associations of their disease complexity, demographic characteristics, comorbidities, insurance status, and primary language with their HbA1c level over time.Methods: Adult patients with diabetes with at least 3 distinct primary care visits between January 1, 2006, and December 31, 2013, were identified in the CHARN data warehouse. These patients were categorized into 4 groups: those without a diagnosis of cardiovascular disease (CVD) or depression; those with CVD but not depression; those with depression but not CVD; and those with CVD and depression. Charlson score; demographic characteristics such as age, sex, and race/ethnicity; and SDHs such as primary language and insurance status were used as predictors. The outcome measure was HbA1c. Hypothesis testing was conducted using 3-level hierarchical linear models.Results: Baseline HbA1c differed significantly across the 4 diabetes groups and by race/ethnicity. The amount of HbA1c change over time differed by insurance status. Patients who were continuously insured tended to have lower baseline HbA1c and a smaller increase. Chinese-speaking patients tended to have lower baseline HbA1c but a larger increase over time compared with English speakers. There were various unexpected associations: compared with the diabetes-only group, mean HbA1c tended to be lower among the other more complex groups at baseline; women tended to have lower measures at baseline; older age and higher Charlson scores were associated with lower HbA1c.Conclusions: There is still unexplained variability relating to both baseline HbA1c values and change over time in the model. SDHs, such as insurance status and primary language, are associated with HbA1c, and results suggest that these relationships vary with disease status among patients with diabetes in safety-net centers. It is important to recognize that there are complex relationships among demographic and SDH measures in complex patients, and there is work to be done in correctly modeling and understanding these relationships. We also recommend prioritizing the collection of SDH and enabling services data for safety-net patients that would be instrumental in conducting a more comprehensive study. 3-7 Interest in studying and describing SDHs has increased over the past few decades, 8 -10 and it is clear that SDHs are associated with suboptimal health status or poor health-related outcomes, 11 such as higher rates of mental disorders and medical conditions. 12 In a meta-analysis conducted by Lorant and colleagues, 13 people with a low socioeconomic status were 1.8 times more likely to report being depressed than were people with higher status. Lett et al 14 also found that low social support was associated with a 1.5-to 2-times increased the risk of developing coronary heart disease or ex...

Personalized medicine and Hispanic health: improving health outcomes and reducing health disparities – a National Heart, Lung, and Blood Institute workshop report

“… Research in community clinical settings offers the possibility of collecting new data and accessing existing relevant data, addressing patient-centered concerns, and improving patient care outcomes. Clinical settings provide the ability to identify potential research participants with specific exposures or diagnoses through EHR, ascertain health outcomes, validate diagnosis codes, estimate disease or risk factor incidence rates, and identify persons with new disease onset [ 51 , 102 ]. In addition, having access to health care providers in clinical settings may illuminate barriers and facilitators to recommended care guidelines.…”

“… Results of research based in clinical settings can be more generalizable. The patients served in community clinical settings or health systems experience a broad range of healthcare environments, social determinants of health, and complex co-morbidities [ 51 ]. The results of research studies in these settings would be more representative of those communities than results of research carried out in academic settings, which tend to be highly selective with respect to patients, providers and healthcare environments [ 49 – 52 ].…”

Association of the Social Determinants of Health With Quality of Primary Care

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