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Diabetes Outcomes Related to Socioeconomic StatusTifenie Harris, Michelle Johnston, Rhonda Jones, Rebecca H. Joostens, and Dana SartoriusFerris State UniversityDiabetes Outcomes Related to Socioeconomic StatusAre diabetic adults who have low socioeconomic status (SES) at increased risk for diabetic complications and poor clinical outcomes compared to diabetic adults with high SES? This question is important because there are many diabetic adults that are being admitted to hospitals due to complications of diabetes. There are many different reasons that diabetic adults suffer from complications related to their diabetes. Some of these reasons include: lack of education and non-compliance with medications and poor diets. Because of this increased number of diabetic admissions, we wanted to know if the patients’ SES put him/her at an increased risk for diabetic complications. To answer this question, four different studies were reviewed with a particular interest in the clinic outcomes of those with low versus high SES. Although further research is still needed, according to these articles there is evidence to prove that SES does play an important role in the outcome of diabetic patients.Summary of Available EvidenceA search of literature was conducted by five group members individually to address this research question: What does the literature reveal about poor clinical outcomes of diabetic adult with low SES and further narrowed by using the PICO question: Are diabetic adults who have low SES at risk for diabetic complications and poor clinical outcomes compared to diabetic adults with high SES? Each person was responsible for presenting two articles to the group. All members reviewed and critiqued the ten articles then selected the top four individual choices based on which articles provided the most relevant and best evidence to address the research and PICO questions. One chosen articles was preferred by every group member and the other three articles had been chosen as preferred by four out of five of the members. A list of the final four articles was presented to and agreed upon by all members. All four articles were the presentation of original research from peer reviewed journals and all researchers had advanced degrees.Article OneA cross-sectional prevalence study of 135 hospitalized diabetic patients in France was studied to explore the relationship between several components of SES with glycemic control and diabetic complications (Bihan et al., 2005). Each participant was given a survey using the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) tool that addresses eleven SES questions and includes both social and material components. A total of 123 participants completed the survey; the 12 participants that did not complete the survey were excluded from the study. The survey was compared and analyzed with the variables of glycemic control, cardiovascular risk factors, retinopathy, neuropathy, and renal disease. The authors performed a regression analysis to adjust for confounding variables (Bihan et al., 2005).The researchers predicted that there was a relationship between poor diabetic control and complications with low SES. Data supported the relationship between low SES and poor glycemic control, retinopathy, neuropathy, and anemia but no correlation with cardiovascular or renal risk factors. The unexpected finding was an association between the presence of anemia and low SES (Bihan et al., 2005). The authors did not discuss areas that could benefit from additional research but discussed in details the limitations of the study which infers to topics that need to be researched further. Information was given on how to integrate the supported evidence into current practice.Article TwoSims et al. (2011) performed a retrospective study with data collected from a previous cohort heart study to examine SES indicators (education, income, and occupation) and diabetic prevalence, awareness, treatment, and control. The original study included 5,301 participants, all African American men and women, from the Jackson, Mississippi area over a four year time frame. Only 4,303 were included in this study due to missing information from 998 participants. Statistical regression analysis was performed on key areas of data collected from the original study to determine the patterns related to low SES and the areas of diabetes the researchers were addressing (Sims et al., 2011).The researchers predicted that low SES impacts prevalence, awareness, treatment, and control of diabetes. Data supported the hypothesis that prevalence was affected by low SES but that there was not a strong relationship between awareness and treatment and no effect was detected for diabetic control (Sims et al., 2011). The authors discussed areas that need further research and also discussed how the results from this study can be translated into current practice.Article ThreeConnolly and Kesson (1996) conducted a cross sectional prevalence study in Glasgow, U.K. on 1,553 participants that attended a diabetic clinic. Data was collected with each visit at the clinic that included age, gender, demographics, biometrics, and biochemical screenings. SES was determined by area zip code information; public records provided statistical information on SES specifics for each zip code. Seven different levels of SES were delineated. The researchers focused on five cardiovascular risk factors of diabetic patients: obesity, hypertension, hypercholesterolemia, smoking, and poor glycemic control that were compared to the SES of each participant. The information was also divided into insulin dependent and non-insulin dependent diabetic diagnosis.The researchers predicted that low SES diabetic patients were at higher risk for cardiovascular disease than higher SES diabetic patients. Data was statistically analyzed comparing SES with each of the five risk factors on all participants. The data presented showed a strong relationship between low SES diabetics and cardiovascular risk factors. The data collected also indicated that the proportion of low SES diabetics that had three or more risk factors was greater than high SES diabetics (Connolly & Kesson, 1996). The authors provided areas where further research is warranted and how the information presented can be incorporated into current practice.Article FourRobbins and Webb (2006) conducted a retrospective study to assess the correlation with low SES minority diabetic patients and hospitalization rates. Data was retrieved during an eight year time period and collected from nine Philadelphia, Pennsylvania area clinics that provide services to low income, racially diverse patients. Hospital admission and discharge information was obtained from State databases and linked to patients that attended the outpatient clinics. Philadelphia clinic databases identified 19,437 patients; 637 were excluded due to missing or conflicting data resulting in a total of 18,800 patients that were included in the study. Statistical analysis was performed on four categories: gender, race/ethnicity, age, and number of hospitalizations with the cost of hospitalization included.The researchers hypothesized that increased hospitalization rates are present in low income racially/ethnically diverse populations. The data presented did not support the hypothesis. The hospitalization rates were higher for racial/ethnic patients in this study but when compared to other population groups from other studies no statistical significance of higher rates of hospitalizations was noted. The researchers indicate that more research is needed in this area; with this group of patients to discover the rationale of the findings. They also discuss the possibility of providing medication and diabetic supplies to low income patients, and supportive services that were offered at the health clinics may contribute to prevention of hospitalization (Robbins & Webb, 2006). The authors provide direction on further research and concepts that can be integrated into current practice.Critical Appraisal of the EvidenceThe review of literature revealed evidence that answers the PICO of whether diabetic patients with low SES have a greater chance of poor clinical outcomes than diabetic patients who have a higher SES. The four articles were reviewed and the evidence was evaluated to determine whether the results were usable and relevant to this topic. The different aspects evaluated were the problem statement, purpose, hierarchy of evidence, and applicability of results. Article OneThe problem identified for study in the article by Bihan et al. (2005) was that there is a relationship between “poor glycemic control and/or some diabetes complications to low socioeconomic status” (pp. 2680). This problem addresses the research question proposed: do diabetics with low SES have an increased risk of poor clinical outcomes than diabetics of higher SES. The problem statement is one that has clinical significance and identifies a problem that can be addressed by changing clinical practice. The purpose of the article by Bihan et al. (2005) states “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” (pp. 2680). This was a feasible study that fit the problem statement. The study identifies itself as the first study of its kind which could indicate a lack of supporting research of this specific study question. The hierarchy of levels of evidence for this study was level IV because it was a nonexperimental research design which indicates that that the study could have stronger evidence. (Nieswiadomy, 2012).The results of the study by Bihan et al. (2005) show that the higher the level of deprivation, indicated by an EPICES score greater than 38.5, the more likely to have poor glycemic control and poor clinical outcomes. Bihan et al. (2005) did not find that there was a relationship between the EPICES score and nephropathy or cardiovascular risk factors, just between the EPICES score and neuropathy, retinopathy, and 1-day hospital stays. Bihan et al. (2005) concludes that deprivation status is associated with poor metabolic control and more frequent microvascular complications. 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. The results suggest that practice implements the EPICES score to identify people who need more specific education and policies for diabetes management.Article TwoThe problem statement for the article by Sims et al. (2011) is “Little research has focused on the social patterning of diabetes among African Americans” (pp. 892). This is a problem that has clinical significance and relates to the PICO identified previously. Sims et al. (2011) states its purpose is “We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans” (pp. 892). The researchers hypothesized that lower SES would be associated with these factors (Sims et al, 2011). 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. The research approach fit the problem being studied by using a quantitative random sample study, cross sectional design from cohort. The hierarchy of evidence is level IV because it is evidence from a case/cohort study (Ursuy, 2013). The article could have had a higher level on the hierarchy of levels of evidence. (Nieswiadomy, 2012)The results reveal the control of diabetes was not clearly patterned by socioeconomic factors, which does not answer the PICO. They do show a relationship between SES and diabetes prevalence. Results show that diabetes prevalence is patterned by SES and that there is a need to address factors that place those of low SES at higher risk. The results were mixed for associations between low SES and awareness and treatment of diabetes. The article is usable and scientifically sound. The results were beneficial to practice by showing that the 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 (Sims et al., 2011). The study indicates there is a need to address factors that place those of low SES at higher risk.Article ThreeThe problem statement of Connolly and Kesson (1996) deals with 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. The purpose of this study was “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. The study was a cross sectional prevalence study which is less expensive and easier to conduct than a longitudinal study and fit the purpose of the study (Nieswiadomy, 2012). The hierarchy of evidence was level IV a case/cohort study (Ursuy, 2013). This study could be higher on the hierarchy of levels of evidence and have more reliable evidence. (Nieswiadomy, 2012)The results of the study by Connolly and Kesson (1996), reveal that 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. This study can influence practice through identifying a need to develop programs targeting low SES, and explaining benefits of risk factor correction within their environment. Connolly and Kesson (1996) call for more research into “impact of social deprivation on diabetes” (pp. 421). The results are usable to address how SES impacts poor clinical outcomes. The subjects were not randomized which may have skewed the results obtained.Article FourThe problem statement of the article by Robbins and Webb (2006) defines that diabetes is a growing health concern. The topic of diabetes is important for clinical practice. The researchers state their purpose is “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). The main purpose of the study does not focus on the question proposed by the PICO, but can yield relevant results. The methods of the study were feasible and were appropriate for the purpose of the study. The hierarchy of evidence was level IV because it was evidence from a case/cohort study (Ursuy, 2013). Nieswiadomy (2012) states that the higher the level of evidence on the hierarchy of levels of evidence, the stronger the source of evidence. This study could be a higher level and a better source of evidence.The main results of the study by Robbins and Webb (2006) show that patients with diabetes experience complicated clinical outcomes that require hospitalization. In addition, the results suggest that expanding access to care and decreasing financial barriers could improve diabetic care for patients with low SES (Robbins & Webb, 2006). 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 the cost of care.Integration of the EvidenceThe evidence suggests that there is a higher prevalence of diabetes and more complications from 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.Student experiencesPatients 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. It seems that there are not enough interventions available to this population to improve the status of their health or increase their accessibility to healthcare. There is evidence that suggests 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 and we want to help all people of each SES. The patients that have lost control of their healthcare need more intervention to help decrease their barriers to caring for themselves and to put control back into their hands. Competing demands such as being a head of household for a single parent family, having no childcare services, or working multiple jobs can be barriers to healthcare so interventions should be developed to assist in overcoming these barriers. Many benefits could be seen from development and implementation of interventions.Patient PreferencesPatients may have many barriers to healthcare. With competing life demands, health care often takes a back seat. Those without family support, no source of income, or no means of transportation may not be able to participate in an educational program, therefore, interventions need to be creative and directed toward the population with low SES and their common barriers. Patients of a low SES often have either no insurance or insurance provided by the government. In their study of 18,800 hospital patients, Robbins and Webb (2006), found that “Forty-one percent had no insurance, 16% had Medicaid, 27% had Medicare, 8% had private insurance, and 8% were recorded as having some other type of insurance” (pp. 1261). The government insurance provided to patients of a low SES may have limitations in coverage or only select providers may accept it, which limits the patient’s access to healthcare. Along with these barriers is the cost of the healthcare provided, and the time spent in the hospital or at doctors’ visits. 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). This amount is not including the lost wages for time hospitalized or cost of childcare services that may have been needed during that time.Nursing ValuesThe nurse has a duty to his/her patients to care for them and provide them with the best quality of care. Implementation of evidence is one way the nurse can improve the health of those he/she cares for. Along with improving the health of patients, the nurse can work to keep healthcare costs low. In their study of 18,800 patients Robbins and Webb (2006) found, “total hospital costs were $818,749,563 or $9,414 per person year of follow-up. The mean charges per hospital admission were $26,820” (pp. 1262). The cost savings in developing interventions targeted at the population with low SES is worth the effort to create interventions that will overcome barriers.The healthcare team may also come across barriers to developing and implementing interventions. The barriers that may be present for healthcare workers are: time, funding, and lack of outside resources. The process of developing and implementing new interventions is time consuming and costly. The lack of resources within the community in which the patients live may also be a barrier because of the lack of resources to continue the interventions in all healthcare settings and within the communities. 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). If there is no way to continue education to the population within their own communities, then the interventions may not be successful. With the evidence showing an increase in complications and or prevalence of diabetes in those with a low SES, intervention is needed.Recommendations to Utilize the EvidenceThese articles reveal that low SES either increases the prevalence of diabetes in low SES populations and/or leads to poor clinical outcomes of diabetes in this and other populations. As nurses, our purpose for literature review is to implement evidence based practiced into our work. Looking at these articles, we can make several recommendations for changes in practice; these include evaluating patients for deprivation or socioeconomic disparities, encouraging health seeking behaviors and improving education on disease prevention in low SES populations. The literature also suggests the need for interventions that are beyond the scope of the nursing profession. This includes increasing access to primary care physicians through both increasing panel sizes and decreasing health care cost.Evaluation for DeprivationIn order to be able to better treat patients with low SES, one needs to be able to identify these patients. Patients in this high risk group should be identified at the hospital so as to confirm the patient’s capability of obtaining health care support upon discharge. Even more preferably, patients should be identified by primary care physicians as low SES so as to prevent disease and hospitalization. Bihan et al. (2005) provided a tool in their research, called EPICES, designed to screen for deprivation. While identification of these patients would be invaluable, time constraints, both in the out-patient clinic as well as in the hospital unit, would likely deter many nurses from utilizing this tool. Another consideration before implementation is that once low SES individuals are identified, it is unlikely that an extensive community resources referral process is available. Clinicians are likely not able to single-handedly resolve socioeconomic issues for the patients. A literature review of studies utilizing nurses and/or social workers to overcome these problems (through use of community resources) and comparing clinical outcomes would be of interest prior to moving forward with an SES screening tool.Primary Prevention versus Secondary PreventionMuch information was given in these studies indicating that nursing interventions would be more effective if directed at primary prevention of diabetes rather than secondary prevention once diagnosis has already been made. While there was discrepancy in the data regarding worsening clinical outcomes in low SES populations, all literature agreed that prevalence of non-insulin dependent diabetes was significantly increased in low SES populations. Thus, nursing interventions preventing the disease itself are likely more impactful than education post diagnosis. According to Connelly and Kesson (1996), in their article Socioeconomic Status and Clustering of Cardiovascular Disease Risk Factors in Diabetic Patients, “the uptake of primary care health checks was lowest in the lowest social, suggesting that the impact of health education will be of little benefit; thus novel approaches to health are required” (pp. 421). Sims et al. (2011) agrees: “These results show that effects to prevent diabetes should focus on the factors that lead to greater risks in low SES African Americans…addressing the underlying causes of these disparities is important for reducing disease burden in African Americans” (pp. 897).Primary Care Nurses have unique advantage over hospital nurses (who are presented with the currently ill patients) and should be utilized for population management to target at-risk populations for disease prevention education. Connelly and Kesson (1996) state “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) thus supporting the use of nursing talent and time prior to the onset of disease.Access to Health CareAlthough nurses may be used in the future to impact this, nurses currently do not have the capability alone to affect the need for increased access to primary care and pharmacy for low SES individuals. “Efforts to improve outcomes for diabetic patients should include efforts to expand such access (to primary care physicians) and to resist policy changes that would create additional financial barriers to care” (Robbins & Webb, 2006, pp. 1263). Nurse leaders and those involved in local politics can and should resist policy changes that may increase health care cost. This can, in turn, improve the community’s access to health care and therefore allow better primary prevention in high risk populations.ConclusionThe articles were able to help answer the question that was presented: are diabetic adults who have low SES at risk for diabetic complications/poor clinical outcomes compared to diabetic adults with high SES? According to the four articles that were reviewed, low SES increases the risk for diabetic complications. Adults with low SES are at increased risk for diabetic complications because they lack the resources needed to buy medications, the ability to obtain medical services and the education needed to know how to self-manage their diet and lifestyle. Further research needs to be done on this topic.To help prevent diabetic complications, the nursing community needs processes in place to screen for at risk individuals, the time to educate at-risk individuals and processes to educate patients on how to self-manage their disease after diagnosis. Efforts need to go beyond nurses to include an interdisciplinary approach. More community resources, such as educational classes, need to be set up in areas that have low SES. If risk factors can be identified and decreased it may be possible to help decrease the number of individuals who develop diabetes and/or who suffer life changing complications from diabetes.ReferencesBihan, 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 , V. M., & Kesson, C. M. (1996). Socioeconomic status and clustering ofcardiovascular disease risk factors in diabetic patients. Diabetes Care, 19(5), 419-422. doi:10.2337/diacare.19.5.419Nieswiadomy, R. M. (2012). Foundations of nursing research (6th e.d). Upper Saddle River, NJ: Pearson.Robbins, J. M., & Webb, D. A. (2006). Hospital admission rates for a racially diverselow-income cohort of patients with diabetes: The urban diabetes study. American Journal of Public Health, 96(7), 1260-1264. doi:10.2105/AJPH.2004.059600Sims, 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.2011.05.006Ursuy, P. (2013). Critique of research. [Powerpoint slides]. Retrieved from ................
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