Diabetes: Are Poor Clinical Outcomes Associated with Low Socioeconomic Status?

1. Diabetes: Are Poor Clinical Outcomes Associated with Low Socioeconomic Status? Tifenie Harris Michelle Johnston, Rhonda Jones Rebecca Joostens Dana Sartorius

2. INTRODUCTION • Group Topic: Chronic Disease • Research Question: What does the literature reveal about poor clinical outcomes of diabetic adults with a low socioeconomic status (SES). • Why we chose this topic: There are many adult diabetics that are being seen in the hospitals with complications from their diabetes. • The complications from their diabetes can be caused by many different factors. We need to find out if diabetic adults are more prone to complications due to their SES. If their SES is a key factor, then we need to find out the barriers that are caused by their SES status and figure out what we can do to help eliminate those barriers. • Four different articles based on the study of SES and the effects it has on diabetic complications in adults compared to their SES were reviewed to see if answers could be found to the question that was presented.

3. PICO QUESTION • Are diabetic adults who have low SES at increased risk for diabetic complications/ poor clinical outcomes compared to diabetic adults with high SES? • Clinical Setting: Urban Free Clinic

4. SUMMARY OF AVAILABLE EVIDENCE The literature search was guided by the research question and narrowed by the PICO question. Two articles were submitted by each group member for selection review. Each group member reviewed the ten articles and submitted what they felt were the four best articles that were the best representation of the research and PICO questions. Consensus was reached on the final four articles.

5. Articles Reviewed Article One- Association Among Individual Deprivation, Glycemic Control, and Diabetes Complications: The EPICES Score. Article Two- The Socioeconomic Gradient of Diabetes Prevalence, Awareness, Treatment, and Control Among African Americans in the Jackson Heart Study. Article Three- Socioeconomic Status and Clustering of Cardiovascular Disease Risk Factors in Diabetic Patients. Article Four- Hospital Admission Rates for a Racially Diverse Low-Income Cohort of Patients With Diabetes: The Urban Diabetes Study.

6. SUMMARY OF AVAILABLE EVIDENCE ARTICLE ONE This is a study on the relationship of several components of SES with glycemic control and diabetic complications. 123 participants of hospitalized patients in France completed a multifaceted SES survey tool that was used to compare individual glycemic control, cardiovascular risks, retinopathy, neuropathy, and renal disease. Researchers predicted a relationship between poor diabetic control and complications with low SES. The data supported the relationship between low SES and poor glycemic control, retinopathy, neuropathy, and anemia. No correlation was found with low SES and cardiovascular or renal disease risk factors. The authors provided direction on areas that need additional research and how the evidence could be integrated into current practice. (Bihan et al., 2005)

7. SUMMARY OF AVAILABLE EVIDENCE ARTICLE TWO This is a study that examined the relationship of SES indicators (education, income, and occupation) with diabetic prevalence, awareness, treatment, and control. A retrospective study used data collected from a heart study on African American men and women in Jackson, Mississippi that was over a four year time frame. Data was analyzed on 4,303 patients. Statistical regression was performed on the areas of interest. The researchers predicted that low SES effects prevalence, awareness, treatment, and control of diabetes. The data supported that diabetic prevalence was affected by low SES Little to no correlation was noted between diabetic awareness, treatment, and control. The authors provided direction on areas that need additional research and how the evidence could be integrated into current practice. (Sims et al., 2011)

8. SUMMARY OF AVAILABLE EVIDENCE Article Three • This is a study that examined the relationship between SES of diabetic patients with five cardiovascular risk factor: obesity, hypertension, hypercholesterolemia, smoking, and poor glycemic control. • A cross sectional prevalence study included 1,553 participants that attended a diabetic clinic. Data was collected on age, gender, demographics, biometrics, and biochemical screenings. Zip code information was uses along with statistics from public reporting of SES for the zip codes. • The researchers predicted that low SES diabetic patients were at higher risk for cardiovascular disease than diabetic patients with higher SES. • The data demonstrated a strong relationship between low SES diabetic patients and the occurrence of cardiovascular risk factors. • The data additionally indicated low SES diabetic patients had a larger reporting of three or more cardiovascular risk factors. • The authors provided direction on areas that need additional research and how the evidence could be integrated into current practice. (Connolly & Kesson, 1996)

9. SUMMARY OF AVAILABLE EVIDENCE Article Four • This is a study that examined the relationship between low SES minority diabetic patients and hospitalization rates. • This was a retrospective study that reviewed data over an eight year time frame from Philadelphia, Pennsylvania clinics that provided services to low income, racially diverse patients. Clinic data was linked with hospital admission and discharge data on 18,800 patients. Statistical analysis was preformed on four categories gender, race/ethnicity, age, and number of hospitalizations with the cost of hospitalization included. • Researchers predicted that there was a relationship between increased hospitalization rates with low SES minority populations. • The data presented did not support the prediction. • Hospitalization rates were higher with low SES minority patients but when compared to population groups from other studies there was no statistical significance in higher hospitalization rates. • The researchers inferred areas that were amiable to further research and gave concepts related to the study that could be integrated into current practice. (Robbins & Webb, 2006)

10. CRITICAL APPRAISAL:Article One • Problem Statement: Relationship between “poor glycemic control and/or some diabetes complications to low socioeconomic status.” (Bihan et al., 2005). • Purpose: “In the present study, we used an individual index of deprivation, the EPICES score, to determine the relationship among glycemic control, diabetes complications, and individual conditions of deprivation.” (Bihan et al., 2005, pp. 2680) This was a feasible study that fit the problem statement. • Hierarchy of Evidence: level IV -Nonexperimental research design (Nieswiadomy, 2012). • Results: The higher the level of deprivation, the more likely to have poor glycemic control and poor clinical outcomes. The results show there is some support for the idea that diabetics with low SES are at greater risk for poor clinical outcomes than diabetics of higher SES. (Bihan et al., 2005)

11. CRITICAL APPRAISAL: Article Two • Problem Statement: “Little research has focused on the social patterning of diabetes among African Americans.” (Sims et al., 2011, pp. 892) This is a problem that has clinical significance and relates to the PICO identified previously. • Purpose:“We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans.” (Sims et al., 2011, pp. 892) This purpose indicates there could be results that answer the PICO of whether diabetics with lower SES would be more at risk for having poor clinical outcomes than diabetics with higher SES. • Hierarchy of Evidence: Level IV - case/cohort study (Ursuy, 2013) • Results: Show a relationship between SES and diabetes prevalence. Underlying causes of disparities in diabetes between African Americans of different social classes should be addressed to help reduce disease burden and reduce race differences in diabetes . The article is usable and scientifically sound. (Sims et al., 2011)

12. CRITICAL APPRAISAL:Article Three • Problem Statement: How cardiovascular risk factors can directly impact diabetes care . This topic relates to the PICO because cardiovascular risk factors may indicate poor clinical outcomes in the population being studied. • Purpose: “to examine the relationship of socioeconomic status on five risk factors: obesity, hypertension, high cholesterol, smoking, and high HbA1C“ (Connolly & Kesson, 1996, pp.419). The purpose of the study directly relates to the PICO and the results of the study can impact clinical practice. • Hierarchy of Evidence: Level IV - case/cohort study (Ursuy, 2013). • Results: Low SES diabetic patients are at increased risk of cardiovascular disease. This relates to the PICO by showing that diabetics with low SES are more at risk for poor clinical outcomes than diabetics with higher SES. The results are usable to address how SES impacts poor clinical outcomes. (Connelly & Kesson, 1996).

13. CRITICAL APPRAISAL:Article Four • Problem Statement: Defines that diabetes is a growing health concern. Important for clinical practice because of the increasing numbers of people managing the disease. • Purpose: “To determine the frequency and costs of hospitalization and to assess possible racial/ethnic disparities in a large cohort of low-income patients with diabetes who had received primary care at municipal health clinics” (Robbins & Webb, 2006, pp. 1260). Main purpose of the study does not focus on PICO, but can yield relevant results. The methods of the study were feasible and appropriate. • Hierarchy of Evidence: Level IV - case/cohort study (Ursuy, 2013). • Results: Patients with diabetes experience complicated clinical outcomes that require hospitalization. Suggests that expanding access to care and decreasing financial barriers could improve diabetic care for patients with low SES. This relates to the PICO by showing that diabetics with a low SES have a greater risk for diabetic complications than diabetics with a higher SES because of the lack of access to care and cost of care. (Robbins & Webb, 2006).

14. INTEGRATION OF THE EVIDENCE The evidence suggests that there are more complications from and prevalence of diabetes in people of a low SES. With this information we can gather that the development of interventions to decrease barriers to finances and improve access to care and the development of programs that will educate about decreasing risk factors will help to decrease complications in those with a low SES.

15. STUDENT EXPERTISE • Patients with low SES and no health insurance or health insurance provided by the government often are seen with more complications from diabetes or poor management of their diabetes. • This population with its high risk has a need for intervention to improve their access to healthcare and in turn decrease the amount of complications from diabetes. • Evidence suggests that programs made to specifically target individuals of a low SES may help to decrease the complications of diabetes (Connelly & Kesson, 1996). As students, we see the importance of implementing evidence-based practices. • Many patients of a low SES have many life demands. Demands that are competing with health such as being a head of household for a single parent family, having no childcare services, or working multiple jobs may be present barriers so interventions should be developed to assist in overcoming these barriers.

16. PATIENT PREFERENCES • There are many barriers that keep people from caring for themselves. Interventions to decrease these barriers or offer free health care services are needed for the population with low SES. • The complications of diabetes can be costly. Robbins and Webb (2006) found in their study of 18,800 hospital patients with diabetes that the costs were “$9414 per person year of follow-up” (pp. 1262). In the costs of hospitalization also comes missing work days and possibly having to pay for childcare services etc. • There still may be barriers to accessing health care such as no insurance or insurance provided by the government which may have limitations in coverage. In their study of 18,800 hospital patients, Robbins and Webb (2006), found that “Forty-one percent had no insurance, 16% had Medicaid, and 27% had Medicare” (pp. 1261). • Those without family support, no source of income, or no means of transportation may not be able to participate in an educational program. Interventions need to be creative and directed toward the population with low SES and their common barriers.

17. NURSING VALUES • In a study of those with low SES the authors Robbins and Webb (2006) found, “total hospital costs were $818,749,563 or $9414 per person year of follow-up. The mean charges per hospital admission were $26,820” (pp. 1262). To keep healthcare costs low, it is the nurse’s role to implement evidence-based practices. • Connelly and Kesson (1996) suggest “specific programs of health education for people from areas with low SES should be developed, explaining the benefits of risk factor correction within their environment” (pp. 421). • The nurse will implement evidence based practices within his/her practice which will improve the health care of those he/she cares for. • The barriers to implementing intervention for this group of people is the nurse’s time, funding, and other resources within the community where the patients live.

18. RECOMMENDATIONS TO UTILIZE THE EVIDENCE Screen and Evaluate Patients for Deprivation Primary Prevention versus Secondary Prevention Improve Access to Health Care.

19. Screen and Evaluate Patients for Deprivation • Patients in low SES need to be identified in order to intervene appropriately • Screening tools for low SES can be used • Barriers: • Time: not likely to be used as nurses likely do not have time for additional screening tools • Lack of community resources: what referrals can be done once these patients are identified?

20. Primary Prevention versus Secondary Prevention • Data suggests efforts should focus on preventing diabetes as opposed to attempting to impact clinical outcomes once diagnosis has been made. • Clinic RNs could be utilized for population management and focus on disease prevention in this population.

21. Improve Access to Health Care • Access to care needs to improve • Larger physician panel sizes • Decrease health care cost • Nurses can assist in population management • Nurse leaders and those involved in local politics can and should resist policy change that may increase health care cost.

22. CONCLUSION • There is sufficient evidence to prove that low SES can increase the risk for diabetic complications. • There needs to be educational classes set up in the community for adults who have low SES. • The educational classes need to be set up for educating on the prevention of diabetes and the management of diabetes. • The classes need to based on the needs of the adults who have low SES (example: lack of transportation or lack of finances to buy the necessary medications or foods to prevent or control their diabetes). • The more that nurses, doctors, and the community can help to support adults that are at risk of getting diabetes, or who have diabetes, the more we can prevent adults from developing complications from diabetes.

23. REFERENCES Bihan, H., Laurent, S., Sass, C., Nguyen, G., Huot, C., Moulin, J. J.,… Regis Cohen. (2005). Association among individual deprivation, glycemic control, and diabetes complications: The EPICES score. Diabetes Care, 28(11), 2680-2686. Retrieved from http://0find.galegroup.com.libcat.ferris.edu/nrcx/start.do?prodId=NRC Connelly, V. M., & Kesson, C. M. (1996). Socioeconomic status and clustering of cardiovascular disease risk factors in diabetic patients. Diabetes Care, 19(5), 419-422. doi:10.2337/diacare.19.5.419 Nieswiadomy, R. M. (2012). Foundations of nursing research (6the.d). Upper Saddle River, NJ: Pearson. Robbins, J. M., & Webb, D. A. (2006). Hospital admission rates for a racially diverse low- income cohort of patients with diabetes: The urban diabetes study. American Journal of Public Health, 96(7), 1260-1264. doi:10.2105/AJPH.2004.059600 Sims, M., Diez Roux, A. V., Boykin, S., Sarpong, D., Gebreab, S. Y., Wyatt, S. B.,…Taylor, H. A. (2011). The socioeconomic gradient of diabetes prevalence, awareness, treatment, and control among African Americans in the Jackson heart study. Annals of Epidemiology,21(12), 892-898. doi:10.1016/j.annepidem.2011.05.006 Ursuy, P. (2013). Critique of research. [Powerpoint slides]. Retrieved from https://fsulearn.ferris.edu