Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults With Diabetes

Abstract

Background Cost-related non-adherence (CRN) is prevalent among individuals with diabetes and can have significant negative health consequences. We examined health and non-health-related pressures and the use of cost-reducing strategies among the U.S. adult population with and without diabetes that may impact CRN. Methods Data from the 2013 wave of National Health Interview Survey (n=34,557) were used to identify the independent impact of perceived financial stress, financial insecurity with healthcare, food insecurity, and cost-reducing strategies on CRN. Results 11% (n=4,158) of adults reported diabetes. 14% with diabetes reported CRN, compared to 7% without. Greater perceived financial stress (Prevalence Ratio (PR)=1.07 [95% CI: 1.05 to 1.09]), financial insecurity with healthcare (PR=1.6 [95% CI: 1.5 to 1.67]), and food insecurity (PR=1.30 [95% CI: 1.2 to 1.4]) were all associated with a greater likelihood of CRN. Asking the doctor for a lower cost medication was associated with a lower likelihood of CRN (PR=0.2 [95% CI: 0.2 to 0.3]), and 27% with CRN reported this. Other cost-reducing behavioral strategies (using alternative therapies, buying prescriptions overseas) were associated with a greater likelihood of CRN. Conclusions Half of adults with diabetes perceived financial stress, and one-fifth reported financial insecurity with healthcare and food insecurity. Talking to a health care provider about low-cost options may be protective against CRN in some situations. Improving screening and communication to identify CRN and increase transparency of low-cost options patients are pursuing may help safeguard from the health consequences of cutting back on treatment.

Screening for Social Determinants of Health in Michigan Health Centers

“…Individuals living in socioeconomically disadvantaged circumstances are at increased risk of developing chronic medical conditions, face greater barriers to successful disease management, and experience higher rates of both emergency department utilization and inpatient hospital admissions. [1][2][3][4][5][6] Recognizing the importance of social determinants of health (SDH) to health outcomes, utilization, and costs, the National Academy of Medicine, Centers for Disease Control and Prevention, and Centers for Medicare & Medicaid Services have all called for evidencebased initiatives to better screen for and address SDHs in clinical settings. [7][8][9] While growing evidence informs instruments used to screen for SDH, 10 -16 little is known about current screening practices for SDH in clinical settings.…”

1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes—2018

“…Furthermore, there are resources available for the inclusion of standardized sociodemographic variables in electronic medical records to facilitate the measurement of health inequities as well as the impact of interventions designed to reduce those inequities (61-63). Social determinants of health are not always recognized and often go undiscussed in the clinical encounter (57). A study by Piette et al (64) found that among patients with chronic illnesses, two-thirds of those who reported not taking medications as prescribed due to cost never shared this with their physician.…”

“…A study by Piette et al (64) found that among patients with chronic illnesses, two-thirds of those who reported not taking medications as prescribed due to cost never shared this with their physician. In a more recent study using data from the National Health Interview Survey (NHIS), Patel et al (57) found that half of adults with diabetes reported financial stress and one-fifth reported food insecurity (FI). Creating systems-level mechanisms to screen for social determinants of health may help overcome structural barriers and communication gaps between patients and providers (57).…”

“…In a more recent study using data from the National Health Interview Survey (NHIS), Patel et al (57) found that half of adults with diabetes reported financial stress and one-fifth reported food insecurity (FI). Creating systems-level mechanisms to screen for social determinants of health may help overcome structural barriers and communication gaps between patients and providers (57). In addition, brief, validated screening tools for some social determinants of health exist and could facilitate discussion around factors that significantly impact treatment during the clinical encounter.…”

“…(54)(55)(56)(57)(58). Social determinants of health are defined as the economic, environmental, political, and social conditions in which people live and are responsible for a major part of health inequality worldwide (59).…”