title: Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study.
abstract: OBJECTIVE
  Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs (hereinafter referred to as material need insecurities). How specific material need insecurities relate to clinical outcomes and the use of health care resources in a setting of near-universal access to health care is unclear.
  
  
  OBJECTIVE
  To determine the association of food insecurity, cost-related medication underuse, housing instability, and energy insecurity with control of diabetes mellitus and the use of health care resources.
  
  
  METHODS
  Cross-sectional data were collected from June 1, 2012, through October 31, 2013, at 1 academic primary care clinic, 2 community health centers, and 1 specialty center for the treatment of diabetes mellitus in Massachusetts. A random sample of 411 patients, stratified by clinic, consisted of adults (aged ≥21 years) with diabetes mellitus (response rate, 62.3%).
  
  
  METHODS
  The prespecified primary outcome was a composite indicator of poor diabetes control (hemoglobin A1c level, >9.0%; low-density lipoprotein cholesterol level, >100 mg/dL; or blood pressure, >140/90 mm Hg). Prespecified secondary outcomes included outpatient visits and a composite of emergency department (ED) visits and acute care hospitalizations (ED/inpatient visits).
  
  
  RESULTS
  Overall, 19.1% of respondents reported food insecurity; 27.6%, cost-related medication underuse; 10.7%, housing instability; 14.1%, energy insecurity; and 39.1%, at least 1 material need insecurity. Poor diabetes control was observed in 46.0% of respondents. In multivariable models, food insecurity was associated with a greater odds of poor diabetes control (adjusted odds ratio [OR], 1.97 [95% CI, 1.58-2.47]) and increased outpatient visits (adjusted incident rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]) but not increased ED/inpatient visits (IRR, 1.00 [95% CI, 0.51-1.97]). Cost-related medication underuse was associated with poor diabetes control (OR, 1.91 [95% CI, 1.35-2.70]) and increased ED/inpatient visits (IRR, 1.68 [95% CI, 1.21-2.34]) but not outpatient visits (IRR, 1.07 [95% CI, 0.95-1.21]). Housing instability (IRR, 1.31 [95% CI, 1.14-1.51]) and energy insecurity (IRR, 1.12 [95% CI, 1.00-1.25]) were associated with increased outpatient visits but not with diabetes control (OR, 1.10 [95% CI, 0.60-2.02] and OR, 1.27 [95% CI, 0.96-1.69], respectively) or with ED/inpatient visits (IRR, 1.49 [95% CI, 0.81-2.73] and IRR, 1.31 [95% CI, 0.80-2.13], respectively). An increasing number of insecurities was 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]; IRR for ED/inpatient visits, 1.22 [95% CI, 0.99-1.51]).
  
  
  CONCLUSIONS
  Material need insecurities were common among patients with diabetes mellitus and had varying but generally adverse associations with diabetes control and the use of health care resources. Material need insecurities may be important targets for improving care of diabetes mellitus.
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, Boston2Diabetes Unit, Massachusetts General Hospital, Boston3Harvard Medical School, Boston, Massachusetts.
authors.forename: Seth A
authors.initials: SA
authors.lastname: Berkowitz
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, Boston3Harvard Medical School, Boston, Massachusetts.
authors.forename: James B
authors.initials: JB
authors.lastname: Meigs
authors.affiliation: Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill.
authors.forename: Darren
authors.initials: D
authors.lastname: DeWalt
authors.affiliation: Division of General Internal Medicine, University of California, San Francisco6Center for Vulnerable Populations, San Francisco General Hospital and Trauma Center, San Francisco, California.
authors.forename: Hilary K
authors.initials: HK
authors.lastname: Seligman
authors.affiliation: currently an undergraduate in the Community Health Program, Tufts University, Medford, Massachusetts8currently an undergraduate in the Biology Program, Tufts University, Medford, Massachusetts.
authors.forename: Lily S
authors.initials: LS
authors.lastname: Barnard
authors.affiliation: currently an undergraduate in the Community Health Program, Tufts University, Medford, Massachusetts.
authors.forename: Oliver-John M
authors.initials: OJ
authors.lastname: Bright
authors.affiliation: currently an undergraduate in the Community Health Program, Tufts University, Medford, Massachusetts.
authors.forename: Marie
authors.initials: M
authors.lastname: Schow
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, Boston3Harvard Medical School, Boston, Massachusetts.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Atlas
authors.affiliation: Diabetes Unit, Massachusetts General Hospital, Boston3Harvard Medical School, Boston, Massachusetts.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Wexler
mesh_terms: D000328:Adult; D000368:Aged; D003920:Diabetes Mellitus / Q000191:economics* / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011203:Poverty / Q000706:statistics & numerical data*