Economic Barriers in Diabetes Management

Economic Barriers in Diabetes Management
Economic Barriers in Diabetes Management
Difficulty paying for food and medications may contribute to poor diabetes control despite increased access to health care in some patients.

Economic concerns, such as food insecurity and problems paying for medications, may hamper diabetes control in some patients, new data published in JAMA Internal Medicine suggest.

Although the Patient Protection and Affordable Care Act will increase access to health care, several studies show that increased coverage will not necessarily improve diabetes control among low-income patients. Rather, “material need insecurities” like difficulty paying for food and medications may get in the way, according to the researchers.

“To strengthen the knowledge base regarding material need insecurities and diabetes mellitus, we simultaneously evaluated several potentially modifiable material need insecurities and their relationship with diabetes control and the use of health care resources,” the researchers wrote.

They evaluated cross-sectional data from 411 patients aged at least 21 years with diabetes collected at one academic primary care clinic, two community health centers and one specialty center for diabetes treatment in Massachusetts from June 1, 2012 to Oct. 31, 2013. Response rate was 62.3%.

Overall, 19.1% of patients reported food insecurity; 27.6% reported cost-related medication underuse; 10.7% reported housing instability; 14.1% reported energy insecurity; and 39.1% reported at least one material need insecurity.

Of all respondents, 46% had poor diabetes control as defined by HbA1c, LDL levels and blood pressure (BP), according to the study results.

Data linked food insecurity to increased odds for poor diabetes control (adjusted OR=1.97; 95% CI, 1.58-2.47) and more outpatient visits (adjusted incident rate ratio [IRR]=1.19; 95% CI, 1.05-1.36). However, it was not associated with increased emergency department (ED) or inpatient visits.

Results also associated underuse of medications due to costs with greater odds of poor diabetes control (OR=1.91; 95% CI, 1.35-2.70) and increased ED or inpatient visits (IRR=1.68; 95% CI, 1.21-2.34) but not outpatient visits.

The researchers also found a link between housing instability (IRR=1.31; 95% CI, 1.14-1.51) and energy insecurity (IRR=1.12; 95% CI, 1.00-1.25) to more outpatient visits, but they were not associated with diabetes control or increased ED or inpatient visits.

Having an increasing number of insecurities was also 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 and IRR for ED or inpatient visits=1.22; 95% CI, 0.99-1.51).

“Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities. In particular, food insecurity and cost-related medication underuse may be promising targets for real-world management of diabetes mellitus,” the researchers wrote.


  1. Berkowitz SA et al. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.6888.