With guidelines and best practice recommendations, treatment/management plans are focused on hitting laboratory targets and physical parameters with the goal of improved outcomes. While the targeting of hemoglobin A1c and blood pressure levels are important as potential determinants of risk of morbidity and mortality, optimization of these parameters only addresses some of the factors relevant to different outcomes.
In a previous issue, Ozieh et al. looked at the individual and cumulative impact of social determinants of health (depression, food insecurity, poverty level) on all cause mortality of 1376 individuals with diabetes and chronic kidney disease. Social determinants of health were significantly associated with mortality even with adjustments for demographics, lifestyle variables, glycemic control, and comorbidities. Depression was independently associated with mortality. Individuals with the presence of all 3 areas had a 41% higher risk of death. There has been recognition by health care providers that socioeconomic factors affect health in terms of access to care, health literacy, and adherence to treatment but the extent of the impact has been underestimated.
With the challenge of packed office/clinic schedules and numerous competing health conditions needing evaluation, the ability to spend time to understand the economic situations or characteristics of a patient’s life is not often available. Physicians may be limiting the ability to treat patients without that information. This understanding would serve to strengthen the provider-patient relationship. Perhaps the approach for the initial assessment for diabetes care, chronic kidney disease or hypertension care would include questions to gauge food insecurity, ability to follow specific diet, or ability to get to appointments.This information would allow creation of feasible plans of care and eliminate the usually inaccurate assumptions that an individual not following a prescribed treatment is a result of lack of care by the patient.
In the last few years, newer agents, such as SGLT-2 inhibitors, have been introduced for management of diabetes with the promise of improved cardiac and renal outcomes. These agents are often expensive and often challenging to get insurance coverage. As research and pharmaceutical development brings us newer options for treatment, we need to remember that only addressing the biochemical parameters with therapeutics will not completely address the health impact of many of our chronic diseases. We need to advocate for investment in case management and social interventions at the same time.