Download Diabetes: Are Poor Clinical Outcomes Associated with Low

Diabetes: Are Poor
Clinical Outcomes
Associated with Low
Socioeconomic
Status?
Tifenie Harris
Michelle Johnston,
Rhonda Jones
Rebecca Joostens
Dana Sartorius
INTRODUCTION
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Group Topic: Chronic Disease
Research Question: What does the literature reveal about
poor clinical outcomes of diabetic adults with a low
socioeconomic status (SES).
Why we chose this topic: There are many adult diabetics
that are being seen in the hospitals with complications from
their diabetes.
The complications from their diabetes can be caused by
many different factors. We need to find out if diabetic
adults are more prone to complications due to their SES. If
their SES is a key factor, then we need to find out the
barriers that are caused by their SES status and figure out
what we can do to help eliminate those barriers.
Four different articles based on the study of SES and the
effects it has on diabetic complications in adults compared
to their SES were reviewed to see if answers could be found
to the question that was presented.
PICO QUESTION
 Are
diabetic adults who have low SES at
increased risk for diabetic complications/
poor clinical outcomes compared to
diabetic adults with high SES?
 Clinical Setting: Urban Free Clinic
SUMMARY OF AVAILABLE EVIDENCE
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The literature search was guided by the research
question and narrowed by the PICO question.
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Two articles were submitted by each group member
for selection review.
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Each group member reviewed the ten articles and
submitted what they felt were the four best articles
that were the best representation of the research and
PICO questions.
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Consensus was reached on the final four articles.
Articles Reviewed
Article One- Association Among Individual Deprivation, Glycemic
Control, and Diabetes Complications: The EPICES Score.
Article Two- The Socioeconomic Gradient of Diabetes
Prevalence, Awareness, Treatment, and Control Among African
Americans in the Jackson Heart Study.
Article Three- Socioeconomic Status and Clustering of
Cardiovascular Disease Risk Factors in Diabetic Patients.
Article Four- Hospital Admission Rates for a Racially Diverse LowIncome Cohort of Patients With Diabetes: The Urban Diabetes
Study.
SUMMARY OF AVAILABLE EVIDENCE
ARTICLE ONE
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This is a study on the relationship of several components of SES
with glycemic control and diabetic complications.
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123 participants of hospitalized patients in France completed
a multifaceted SES survey tool that was used to compare
individual glycemic control, cardiovascular risks, retinopathy,
neuropathy, and renal disease.
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Researchers predicted a relationship between poor diabetic
control and complications with low SES.
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The data supported the relationship between low SES and
poor glycemic control, retinopathy, neuropathy, and anemia.
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No correlation was found with low SES and cardiovascular or
renal disease risk factors.
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The authors provided direction on areas that need additional
research and how the evidence could be integrated into
current practice.
(Bihan et al., 2005)
SUMMARY OF AVAILABLE EVIDENCE
ARTICLE TWO
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This is a study that examined the relationship of SES indicators
(education, income, and occupation) with diabetic
prevalence, awareness, treatment, and control.
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A retrospective study used data collected from a heart study
on African American men and women in Jackson, Mississippi
that was over a four year time frame. Data was analyzed on
4,303 patients. Statistical regression was performed on the
areas of interest.
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The researchers predicted that low SES effects prevalence,
awareness, treatment, and control of diabetes.
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The data supported that diabetic prevalence was affected by
low SES
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Little to no correlation was noted between diabetic
awareness, treatment, and control.
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The authors provided direction on areas that need additional
research and how the evidence could be integrated into
current practice.
(Sims et al., 2011)
SUMMARY OF AVAILABLE EVIDENCE
Article Three
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This is a study that examined the relationship between SES of
diabetic patients with five cardiovascular risk factor: obesity,
hypertension, hypercholesterolemia, smoking, and poor glycemic
control.
A cross sectional prevalence study included 1,553 participants that
attended a diabetic clinic. Data was collected on age, gender,
demographics, biometrics, and biochemical screenings. Zip code
information was uses along with statistics from public reporting of
SES for the zip codes.
The researchers predicted that low SES diabetic patients were at
higher risk for cardiovascular disease than diabetic patients with
higher SES.
The data demonstrated a strong relationship between low SES
diabetic patients and the occurrence of cardiovascular risk factors.
The data additionally indicated low SES diabetic patients had a
larger reporting of three or more cardiovascular risk factors.
The authors provided direction on areas that need additional
research and how the evidence could be integrated into current
practice.
(Connolly & Kesson, 1996)
SUMMARY OF AVAILABLE EVIDENCE
Article Four
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This is a study that examined the relationship between low SES
minority diabetic patients and hospitalization rates.
This was a retrospective study that reviewed data over an eight
year time frame from Philadelphia, Pennsylvania clinics that
provided services to low income, racially diverse patients. Clinic
data was linked with hospital admission and discharge data on
18,800 patients. Statistical analysis was preformed on four
categories gender, race/ethnicity, age, and number of
hospitalizations with the cost of hospitalization included.
Researchers predicted that there was a relationship between
increased hospitalization rates with low SES minority populations.
The data presented did not support the prediction.
Hospitalization rates were higher with low SES minority patients but
when compared to population groups from other studies there was
no statistical significance in higher hospitalization rates.
The researchers inferred areas that were amiable to further
research and gave concepts related to the study that could be
integrated into current practice.
(Robbins & Webb, 2006)
CRITICAL APPRAISAL:
Article One
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Problem Statement: Relationship between “poor glycemic
control and/or some diabetes complications to low
socioeconomic status.” (Bihan et al., 2005).
Purpose: “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.” (Bihan et al., 2005, pp.
2680) This was a feasible study that fit the problem statement.
Hierarchy of Evidence: level IV -Nonexperimental research
design (Nieswiadomy, 2012).
Results: The higher the level of deprivation, the more likely to
have poor glycemic control and poor clinical outcomes. 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.
(Bihan et al., 2005)
CRITICAL APPRAISAL:
Article Two
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Problem Statement: “Little research has focused on the social
patterning of diabetes among African Americans.” (Sims et al.,
2011, pp. 892) This is a problem that has clinical significance and
relates to the PICO identified previously.
Purpose:“We examined the relationship between
socioeconomic status (SES) and the prevalence, awareness,
treatment, and control of diabetes among African Americans.”
(Sims et al., 2011, pp. 892) 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.
Hierarchy of Evidence: Level IV - case/cohort study (Ursuy, 2013)
Results: Show a relationship between SES and diabetes
prevalence. 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 . The article is usable and scientifically
sound.
(Sims et al., 2011)
CRITICAL APPRAISAL:
Article Three
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Problem Statement: 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.
Purpose: “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.
Hierarchy of Evidence: Level IV - case/cohort study (Ursuy,
2013).
Results: 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. The results are usable
to address how SES impacts poor clinical outcomes.
(Connelly & Kesson, 1996).
CRITICAL APPRAISAL:
Article Four
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Problem Statement: Defines that diabetes is a growing health concern.
Important for clinical practice because of the increasing numbers of
people managing the disease.
Purpose: “To determine the frequency and costs of hospitalization and
to assess possible racial/ethnic disparities in a large cohort of lowincome patients with diabetes who had received primary care at
municipal health clinics” (Robbins & Webb, 2006, pp. 1260). Main
purpose of the study does not focus on PICO, but can yield relevant
results. The methods of the study were feasible and appropriate.
Hierarchy of Evidence: Level IV - case/cohort study (Ursuy, 2013).
Results: Patients with diabetes experience complicated clinical
outcomes that require hospitalization. Suggests that expanding access
to care and decreasing financial barriers could improve diabetic care
for patients with low SES. 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 cost of care.
(Robbins & Webb, 2006).
INTEGRATION OF THE
EVIDENCE
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The evidence suggests that there are more
complications from and prevalence of 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 EXPERTISE
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Patients 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.
This population with its high risk has a need for intervention to
improve their access to healthcare and in turn decrease the
amount of complications from diabetes.
Evidence suggests that 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 evidencebased practices.
Many patients of a low SES have many life demands. Demands
that are competing with health such as being a head of
household for a single parent family, having no childcare
services, or working multiple jobs may be present barriers so
interventions should be developed to assist in overcoming
these barriers.
PATIENT PREFERENCES
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There are many barriers that keep people from caring for
themselves. Interventions to decrease these barriers or offer free
health care services are needed for the population with low SES.
The complications of diabetes can be costly. 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).
In the costs of hospitalization also comes missing work days and
possibly having to pay for childcare services etc.
There still may be barriers to accessing health care such as no
insurance or insurance provided by the government which may
have limitations in coverage. In their study of 18,800 hospital
patients, Robbins and Webb (2006), found that “Forty-one percent
had no insurance, 16% had Medicaid, and 27% had Medicare”
(pp. 1261).
Those without family support, no source of income, or no means of
transportation may not be able to participate in an educational
program. Interventions need to be creative and directed toward
the population with low SES and their common barriers.
NURSING VALUES
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In a study of those with low SES the authors Robbins and Webb
(2006) found, “total hospital costs were $818,749,563 or $9414
per person year of follow-up. The mean charges per hospital
admission were $26,820” (pp. 1262). To keep healthcare costs
low, it is the nurse’s role to implement evidence-based
practices.
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).
The nurse will implement evidence based practices within
his/her practice which will improve the health care of those
he/she cares for.
The barriers to implementing intervention for this group of
people is the nurse’s time, funding, and other resources within
the community where the patients live.
RECOMMENDATIONS TO
UTILIZE THE EVIDENCE
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Screen and Evaluate Patients for Deprivation
Primary Prevention versus Secondary Prevention
Improve Access to Health Care.
Screen and Evaluate Patients
for Deprivation
 Patients
in low SES need to be identified in
order to intervene appropriately
 Screening tools for low SES can be used
 Barriers:
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Time: not likely to be used as nurses likely do
not have time for additional screening tools
Lack of community resources: what referrals
can be done once these patients are
identified?
Primary Prevention versus
Secondary Prevention
 Data
suggests efforts should focus on
preventing diabetes as opposed to
attempting to impact clinical outcomes
once diagnosis has been made.
 Clinic RNs could be utilized for population
management and focus on disease
prevention in this population.
Improve Access to Health
Care
 Access
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to care needs to improve
Larger physician panel sizes
Decrease health care cost
 Nurses
can assist in population
management
 Nurse leaders and those involved in local
politics can and should resist policy
change that may increase health care
cost.
CONCLUSION
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There is sufficient evidence to prove that low SES can
increase the risk for diabetic complications.
There needs to be educational classes set up in the
community for adults who have low SES.
The educational classes need to be set up for educating
on the prevention of diabetes and the management of
diabetes.
The classes need to based on the needs of the adults who
have low SES (example: lack of transportation or lack of
finances to buy the necessary medications or foods to
prevent or control their diabetes).
The more that nurses, doctors, and the community can
help to support adults that are at risk of getting diabetes, or
who have diabetes, the more we can prevent adults from
developing complications from diabetes.
REFERENCES
Bihan, 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
http://0find.galegroup.com.libcat.ferris.edu/nrcx/start.do?prodId=NRC
Connelly, V. M., & Kesson, C. M. (1996). Socioeconomic status and clustering of
cardiovascular disease risk factors in diabetic patients. Diabetes
Care, 19(5), 419-422. doi:10.2337/diacare.19.5.419
Nieswiadomy, 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 diverse lowincome cohort of patients with diabetes: The urban diabetes study.
American Journal of Public Health, 96(7), 1260-1264.
doi:10.2105/AJPH.2004.059600
Sims, 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.2011.05.006
Ursuy, P. (2013). Critique of research. [Powerpoint slides]. Retrieved from
https://fsulearn.ferris.edu