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The Impact of Financial Barriers on Access to Care, Quality of Care and Vascular Morbidity Among Patients with Diabetes and Coronary Heart Disease

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ABSTRACT

BACKGROUND

The prevalence and consequences of financial barriers to health care among patients with multiple chronic diseases are poorly understood.

OBJECTIVE

We sought to assess the prevalence of self-reported financial barriers to health care among individuals with diabetes and coronary heart disease (CHD) and to determine their association with access to care, quality of care and clinical outcomes.

DESIGN

The 2007 Centers for Disease Control Behavioral Risk Factor Surveillance Survey.

PARTICIPANTS

Diabetic patients with CHD.

MAIN MEASURES

Financial barriers to health care were defined by a self-reported time in the past 12 months when the respondent needed to see a doctor but could not because of cost. The primary clinical outcome was vascular morbidity—a composite of stroke, retinopathy, nonhealing foot sores or bilateral foot amputations.

KEY RESULTS

Among the 11,274 diabetics with CHD, 1,541 (13.7 %) reported financial barriers to health care. Compared to individuals without financial barriers, those with financial barriers had significantly reduced rates of medical assessments within the past 2 years, hemoglobin (Hgb) A1C measurements in the past year, cholesterol measurements at any time, eye and foot examinations within the past year, diabetic education, antihypertensive treatment, aspirin use and a higher prevalence of vascular morbidity. In multivariable analyses, financial barriers to health care were independently associated with reduced odds of medical checkups (Odds Ratio [OR], 0.61; 95 % Confidence Intervals [CI], 0.55–0.67), Hgb A1C measurement (OR, 0.85; 95 % CI, 0.77–0.94), cholesterol measurement (OR, 0.76; 95 % CI, 0.67–0.86), eye (OR, 0.85; 95 % CI, 0.79–0.92) and foot (OR, 0.92; 95 % CI, 0.84–1.00) examinations, diabetic education (OR, 0.93; 95 % CI, 0.87–0.99), aspirin use (OR, 0.88; 95 % CI, 0.81–0.96) and increased odds of vascular morbidity (OR, 1.23; 95 % CI, 1.14–1.33).

CONCLUSIONS

In diabetic adults with CHD, financial barriers to health care were associated with impaired access to medical care, inferior quality of care and greater vascular morbidity. Eliminating financial barriers and adherence to guideline-based recommendations may improve the health of individuals with multiple chronic diseases.

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REFERENCES

  1. DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2011, in Current Population Reports, P60-243, U.S. Census Bureau, Editor. Washington, DC 2012.

  2. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med. 2008;149(3):170–6.

    Article  PubMed  Google Scholar 

  3. Schoen C, Doty MM, Robertson RH, Collins SR. Affordable Care Act reforms could reduce the number of uninsured US adults by 70 percent. Health Affairs. 2011;30(9):1762–71.

    Article  PubMed  Google Scholar 

  4. Kaiser Family Foundation. Patient cost-sharing under the Affordable Care Act. 2012. http://www.kff.org/healthreform/upload/8303.pdf. Accessed March 21, 2013.

  5. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health. 2003;93(5):786–91.

    Article  PubMed  Google Scholar 

  6. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Hypertension, diabetes, and elevated cholesterol among insured and uninsured U.S. adults. Health Affairs (Millwood). 2009;28(6):w1151–9.

    Article  Google Scholar 

  7. Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Medical Care. 2004;42(2):102–9.

    Article  PubMed  Google Scholar 

  8. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12):2289–95.

    Article  PubMed  Google Scholar 

  9. Fowler-Brown A, Corble-Smith G, Garrett J, Lurie N. Risk of cardiovascular events and death—does insurance matter? J Gen Intern Med. 2007;22(4):502–7.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Rosen H, Saleh F, Lipsitz S, Rogers SO, Gawande AA. Downwardly mobile. The accidental cost of being uninsured. Arch Surg. 2009;144(11):1006–11.

    Article  PubMed  Google Scholar 

  11. Anderson G. Chronic care: Making the case for ongoing care. Princeton: Robert Wood Johnson Foundation; 2010. http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583.

    Google Scholar 

  12. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47(10):2130–9.

    Article  PubMed  Google Scholar 

  13. American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11–66.

    Google Scholar 

  14. Rosengren A, Welin L, Tsipogianni A, Wilhelmsen L. Impact of cardiovascular risk factors on coronary heart disease and mortality among middle aged diabetic men. A general population study. Br Med J. 1989;299(6708):1127–31.

    Article  CAS  Google Scholar 

  15. Barrett-Connor E, Wingard DL. Sex differential in ischemic heart disease mortality in diabetes. A prospective population-based study. Am J Epidemiol. 1983;118(4):489–96.

    CAS  PubMed  Google Scholar 

  16. Barrett-Connor EL, Cohn BA, Wingard DL, Edelstein SL. Why is diabetes mellitus a stronger risk factor for fatal ischemic heart disease in women than men? JAMA. 1991;265(5):627–31.

    Article  CAS  PubMed  Google Scholar 

  17. He Y. Missing data analysis using multiple imputation: getting to the heart of the matter. Circ Cardiovasc Qual Outcomes. 2010;3:98–105.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Schoen C, Collins SR, Kriss JL, Doty MM. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Affairs. 2008;27(4):w298–309.

    Article  PubMed  Google Scholar 

  19. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220.

    Article  PubMed  Google Scholar 

  20. Cohen RA, Gindi RM, Kirzinger WK. Financial burden of medical care: early release of estimates from the National Health Interview Survey, January–June 2011. National Center for Health Statistics. 2012. Available from: http://www.cdc.gov/nchs/nhis/releases.htm.

  21. Rahimi AR, Spertus JA, Reid KJ, Berhneim SM, Krumholz HM. Financial barriers to health care and outcomes after acute myocardial infarction. JAMA. 2007;297(10):1063–72.

    Article  CAS  PubMed  Google Scholar 

  22. Karter AJ, Ferrara A, Darbinian JA, Ackerson LM, Selby JV. Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes. Diabetes Care. 2000;23(4):477–83.

    Article  CAS  PubMed  Google Scholar 

  23. Heisler M, et al. Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study. Arch Intern Med. 2007;167(17):1853–60.

    Article  PubMed  Google Scholar 

  24. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Public Health. 2006;96(7):1300–7.

    Article  PubMed  Google Scholar 

  25. Schneider KL, Clark MA, Rakowski W, Lapane KL. Evaluating the impact of non-response bias in the Behavioral Risk Factor Surveillance System (BRFSS). J Epidemiol Commun Health. 2012;66(4):290–5.

    Article  Google Scholar 

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Acknowledgements

There are no internal or external sources of funding or sponsors for this study.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

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Authors and Affiliations

  1. Department of Medicine, Division of Cardiovascular Medicine, State University of New York, Stony Brook University Medical Center, Stony Brook, NY, USA

    Puja B. Parikh MD, Steven Leigh BS, Roopali Parikh MD, Nicholas Sakellarios MD & David L. Brown MD

  2. Department of Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA

    Jie Yang PhD, Kunchok Dorjee MD & Hongdao Meng PhD

  3. Department of Medicine, Division of Cardiovascular Medicine, Health Sciences Center, T16-080, Stony Brook, NY, 11794-8160, USA

    David L. Brown MD

Authors
  1. Puja B. Parikh MD
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  2. Jie Yang PhD
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  3. Steven Leigh BS
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  5. Roopali Parikh MD
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  8. David L. Brown MD
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Correspondence to David L. Brown MD.

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Parikh, P.B., Yang, J., Leigh, S. et al. The Impact of Financial Barriers on Access to Care, Quality of Care and Vascular Morbidity Among Patients with Diabetes and Coronary Heart Disease. J GEN INTERN MED 29, 76–81 (2014). https://doi.org/10.1007/s11606-013-2635-6

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  • DOI: https://doi.org/10.1007/s11606-013-2635-6

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