While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Two Robert Wood Johnson Foundation (RWJF) Health & Society Scholars recently published studies examining the interaction between patient income and diabetes. The studies explored different aspects of the subject, but both concluded that health care providers could do more to help low-income patients avoid and manage diabetes.
In a study published in The Diabetes Educator, Dominick Frosch, PhD, examined some of the day-to-day disease-management challenges facing low-income diabetes patients, and how health care providers might help patients overcome them. Frosch is an alumnus of the RWJF Health & Society Scholars program (2003-2005), and a fellow in the Gordon and Betty Moore Foundation’s Patient Care Program and adjunct associate professor of medicine at UCLA.
Frosch and his colleagues piggybacked their research onto a larger study testing methods for supporting patients as they managed the disease. Frosch's team randomly selected 20 of the more than 200 patients in the larger study for in-depth interviews, to identify and understand the daily problems they faced. "For low-income patients, the everyday management of diabetes can be riddled with challenges, including inconsistent access to health care, lack of access to affordable healthful foods, limited transportation, and lack of safe housing," they concluded.
The picture that emerged was one of constant tradeoffs as patients’ management of their diabetes came into conflict with other priorities. The diet recommended by doctors was more expensive than patients could afford, for example, forcing them to choose between paying the rent and eating a healthful diet. For many, the recommended fresh fruits and vegetables simply weren't available in nearby grocery stores.
Some patients found the routine of self-care to be "overwhelming," Frosch found, demanding time and knowledge about food preparation that was simply beyond them. Many found it easier and cheaper simply to buy fast food.
Some patients essentially negotiated with themselves over what they would eat. Rather than buying, preparing, and eating a nutritious meal, they reported eating less healthful but smaller meals. Rather than checking their blood sugar levels with the recommended frequency, they saved on costly medical supplies by checking less frequently.
For Frosch, a key lesson from the study is for providers: "Treatment plans in diabetes care need to be highly individualized," he says, "accounting for what the patient is able and willing to do. So rather than just telling the patient to 'go do this,' providers really need to have a conversation with them that helps determine what the patient is able and willing to do and what the patient's competing priorities are. Then they can develop a treatment plan in collaboration with the patient that is manageable."
Frosch points out that such consultations are not well rewarded by current reimbursement practices. "Primary care providers face enormous time pressures," he says. "Sitting down with patients to have these kinds of conversations isn't really rewarded by reimbursements; such efforts aren’t valued in the same way as doing procedures." But he also observes that providers who invest the time in such conversations might be able to reduce the number of return visits required to keep patients' diabetes under control.
Frosch believes such a transformation in the approach to diabetes will require a long-term effort that includes reforming the ways medical schools teach physicians, and empowering patients to expect a more collaborative relationship with their providers. He sees the move toward medical homes as a positive sign, because the model focuses on keeping patients healthy and emphasizes team-based care. He says, too, that nurses have a growing role to play in helping patients manage their diabetes over time.
The Interplay of Diabetes, Depression, and Neighborhood
Another factor at work in diabetes is depression. For years, researchers have known that depression and diabetes often go hand in hand. As Health & Society Scholar alumnus (2007-2009) Briana Mezuk, PhD, explains, "Thirty years ago, the explanation for that was along the lines of: 'Who wouldn't be depressed about having diabetes?' But then studies showed that depression could predict diabetes prospectively. That makes more sense now, because we have a better appreciation for the behavioral components at work: People who are depressed are more likely to be sedentary, to have a poor diet, to smoke or drink in ways that increase risk of diabetes, and so on. We also have a better appreciation for the physiology of depression, and the hormonal changes that go along with it, which can increase risk of diabetes as well."
But it's not all about physiology, Mezuk is quick to note. "We also know that a lot of contextual factors are related to diabetes risk: living near green space, the walkability of neighborhoods, the number of fast food restaurants, and access to health care—those all play a role, too."
Because such factors are issues in many low-income neighborhoods, Mezuk, as assistant professor in the Department of Family Medicine and Population Health at Virginia Commonwealth University, decided to explore the interaction between neighborhood, depression, and diabetes, wondering whether the known association between depression and diabetes is accelerated for people who live in low-income neighborhoods.
Mezuk and colleagues began their research in Sweden, where a rich database of medical records and robust census data lent itself to the inquiry. Their study, published in Health & Place, examined data from some 336,000 patients, none of whom had been diagnosed with diabetes as of 2001. By 2007, nearly 28,000 had been diagnosed with type 2 diabetes—8.2 percent. The incidence of diabetes among patients who had a lifetime history of major depression, however, was twice as high, confirming the known interplay between depression and diabetes. Individuals living in low-income neighborhoods also had twice the risk of diabetes as those living in high-income neighborhoods, even after accounting for such individual-level socioeconomic factors as education and income.
Finally, the researchers examined whether there was any interaction between depression and neighborhood context on the risk of developing diabetes. Their conclusion: Although diabetes and depression are both more common in low-income neighborhoods, the relationship between depression and diabetes risk was not exacerbated by neighborhood context.
That's good news, Mezuk says, but it doesn't change the harsh reality that diabetes and depression are still more common in low-income neighborhoods.
Like Frosch, Mezuk observes that providers can help by strengthening their communications with low-income patients. "We need intervention strategies for depression that recognize that it's just a part of health," she says. "Psychotherapy is focused on how people perceive and react, and there's no reason not to use that same strategy to talk to people about their health behaviors—including diabetes prevention behaviors—and how that relates to their mood. We should think about group therapy approaches, interpersonal therapy, and family therapy. These are innovative ways we can think about treating diabetes, asthma, depression, and other conditions that require intensive patient health management."
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