The impact of financial barriers on access to care, quality of care and vascular morbidity among patients with diabetes and coronary heart disease.
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.


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


METHODS
Diabetic patients with CHD.


METHODS
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.


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.
Puja B
PB
Parikh
Jie
J
Yang
Steven
S
Leigh
Kunchok
K
Dorjee
Roopali
R
Parikh
Nicholas
N
Sakellarios
Hongdao
H
Meng
David L
DL
Brown
D000368:Aged; D040343:Behavioral Risk Factor Surveillance System; D002784:Cholesterol / Q000097:blood; D003327:Coronary Disease / Q000191:economics / Q000628:therapy*; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000191:economics / Q000628:therapy*; D003925:Diabetic Angiopathies / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D005382:Financing, Personal / Q000706:statistics & numerical data*; D006442:Glycated Hemoglobin / Q000378:metabolism; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D057566:Self Report
D002784:Cholesterol; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents