The Monthly Cycle of Hypoglycemia: An Observational Claims-based Study of Emergency Room Visits, Hospital Admissions, and Costs in a Commercially Insured Population

Income variability and incident cardiovascular disease in diabetes: a population-based cohort study

BACKGROUND AND AIMS

Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D).

METHODS

Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders.

RESULTS

High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results.

CONCLUSIONS

Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study

BACKGROUND

Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is known about physical food insecurity (due to difficulty cooking or shopping for food), which may increase with age, and its association with hypoglycemia.

OBJECTIVE

Study associations between food insecurity and severe hypoglycemia.

DESIGN

Survey based cross-sectional study.

PARTICIPANTS

Survey responses were collected in 2019 from 1,164 older (≥ 65 years) patients with type 2 diabetes treated with insulin or sulfonylureas.

MAIN MEASURES

Risk ratios (RR) for economic and physical food insecurity associated with self-reported severe hypoglycemia (low blood glucose requiring assistance) adjusted for age, financial strain, HbA1c, Charlson comorbidity score and frailty. Self-reported reasons for hypoglycemia endorsed by respondents.

KEY RESULTS

Food insecurity was reported by 12.3% of the respondents; of whom 38.4% reported economic food insecurity only, 21.1% physical food insecurity only and 40.5% both. Economic food insecurity and physical food insecurity were strongly associated with severe hypoglycemia (RR = 4.3; p = 0.02 and RR = 4.4; p = 0.002, respectively). Missed meals ("skipped meals, not eating enough or waiting too long to eat") was the dominant reason (77.5%) given for hypoglycemia.

CONCLUSIONS

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity. Standard food insecurity questions, which are used to identify economic food insecurity, will fail to identify patients who have physical food insecurity only.

Household food insecurity is associated with greater autonomic dysfunction testing score in Latinos with type 2 diabetes

AIM

We examined household food insecurity (HFI) and autonomic nervous system (ANS) function in a subset of low-income Latinos with type 2 diabetes with data from a stress management trial.

METHODS

InclusionLatino or Hispanic, Spanish speaking, age less than 18 years, ambulatory status, type 2 diabetes more than 6 months, A1c less than 7.0%. ExclusionPain or dysfunction in hands (e.g., arthritis) precluding handgrip testing; medical or psychiatric instability. HFI was assessed with the 6-item U.S. household food security survey module; with responses to > = 1 question considered HFI. An ANS dysfunction index was calculated from xix autonomic function tests which were scored 0 = normal or 1 = abnormal based on normative cutoffs and then summed. Autonomic function tests were: 1) 24-hour heart rate variability as reflected in standard deviation of the normal-to-normal (SDNN) heart rate acquired with 3-channel, 7-lead ambulatory electrocardiogram (Holter) monitors; 2) difference between the highest diastolic blood pressure (DBP) during sustained handgrip and the average DBP at rest; 3) difference between baseline supine and the minimal BP after standing up; and, from 24-hour urine specimens 4) cortisol, 5) normetanephrine, and, 6) metanephrine.

RESULTS

Thirty-five individuals participated, 23 (65.7%) of them were women, age mean = 61.6 (standard deviation = 11.2) years, HbA1c mean = 8.5% (standard deviation = 1.6) and 20 participants (57.1%) used insulin. Twenty-two participants (62.9%) reported HFI and 25 (71.4%) had one or more abnormal ANS measure. Independent t-tests showed that participants with HFI had a higher ANS dysfunction index (mean = 1.5, standard deviation = 0.9) than patients who were food secure (mean = 0.7, standard deviation = 0.8), p = 0.02. Controlling for financial strain did not change significance. Total ANS index was not related to glycemia, insulin use or other socioeconomic indicators. In this sample, HFI was associated with ANS dysfunction. Policies to improve food access and affordability may benefit health outcomes for Latinos with diabetes.

6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Mapping Oral health and Local Area Resources (MOLAR): protocol for a randomised controlled trial connecting emergency department patients with social and dental resources

INTRODUCTION

There are substantial inequities in oral health access and outcomes in the USA, including by income and racial and ethnic identity. People with adverse social determinants of health (aSDoH), such as housing or food insecurity, are also more likely to have unmet dental needs. Many patients with dental problems present to the emergency department (ED), where minimal dental care or referral is usually available. Nonetheless, the ED represents an important point of contact to facilitate screening and referral for unmet oral health needs and aSDoH, particularly for patients who may not otherwise have access to care.

METHODS AND ANALYSIS

Mapping Oral health and Local Area Resources is a randomised controlled trial enrolling 2049 adult and paediatric ED patients with unmet oral health needs into one of three trial arms: (a) a standard handout of nearby dental and aSDoH resources; (b) a geographically matched listing of aSDoH resources and a search link for identification of geographically matched dental resources; or (c) geographically matched resources along with personalised care navigation. Follow-up at 3, 6, 9 and 12 months will evaluate oral health-related quality of life, linkage to resources and dental treatment, ED visits for dental problems and the association between linkage and neighbourhood resource density.

ETHICS AND DISSEMINATION

All sites share a single human subjects review board protocol which has been fully approved by the Mass General Brigham Human Subjects Review Board. Informed consent will be obtained from all adults and adult caregivers, and assent will be obtained from age-appropriate child participants. Results will demonstrate the impact of addressing aSDoH on oral health access and the efficacy of various forms of resource navigation compared with enhanced standard care. Our findings will facilitate sustainable, scalable interventions to identify and address aSDoH in the ED to improve oral health and reduce oral health inequities.

TRIAL REGISTRATION NUMBER

NCT05688982.

Exploratory analysis of medication adherence and social determinants of health among older adults with diabetes

Background

Diabetes is the fifth leading cause of death in the United States (US), affecting approximately 27%, or 15.9 million adults 65 years of age and older. Diabetes is the most expensive chronic condition in the US and accounts for the second largest avoidable healthcare cost. Adherence to long-term medication treatment plans is crucial among patients with diabetes because it decreases risk of developing comorbid conditions and improves quality of life. Greater exposure to adverse social determinants of health (SDOH) over an individual's lifespan can result in worse health outcomes. Hence, it is important to obtain a better understanding of how social determinants of health (SDOH) influence patients' behaviors and affect medication adherence among older adults with diabetes.

Objectives

Identify and prioritize SDOH associated with medication adherence among a nationally representative sample of older adults with diabetes. Secondary objectives were to characterize SDOH, estimate medication adherence, and explain implications for health disparity populations among older adults in the US who have been diagnosed with diabetes.

Methods

This study used a cross-sectional secondary data analysis to examine the National Health and Nutrition Examination Survey database, identifying associations between SDOH and medication adherence among older adults with diabetes in the US.

Results

A total of 1807 respondents' data were included in the analyses. Nearly three-quarters (73.9%) of patients were considered adherent to their oral diabetes medications. Multivariable analysis revealed significant differences in medication adherence based on disability status (p = 0.016), household balanced meals (p = 0.033), and interview language (p = 0.008).

Conclusions

Results revealed those with a disability, those who could not afford a balanced meal, and/or those who spoke English were associated with a higher likelihood of being nonadherent to their diabetes medications in comparison to individuals not in these groups. These findings can assist in developing SDOH-centered medication adherence strategies for pharmacists to implement with older patients with diabetes.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status

BACKGROUND

Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits.

OBJECTIVE

This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status.

METHODS

Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response.

RESULTS

Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP.

CONCLUSIONS

Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

Food Insecurity and Diabetes: Overview of Intersections and Potential Dual Solutions

Food insecurity increases the risk of developing diabetes and its complications. In this article, we describe the complex relationship that exists between food insecurity and diabetes and describe potential mechanisms that may underlie this association. We then describe how two different types of interventions, food-is-medicine and federal nutrition assistance programs, may help address both food insecurity and health. Finally, we outline the research, policy, and practice opportunities that exist to address food insecurity and reduce diabetes-related health disparities.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Food Insecurity Trajectories in the US During the First Year of the COVID-19 Pandemic

INTRODUCTION

The objective of this study was to characterize population-level trajectories in the probability of food insecurity in the US during the first year of the COVID-19 pandemic and to examine sociodemographic correlates associated with identified trajectories.

METHODS

We analyzed data from the Understanding America Study survey, a nationally representative panel (N = 7,944) that assessed food insecurity every 2 weeks from April 1, 2020, through March 16, 2021. We used latent class growth analysis to determine patterns (or classes) of pandemic-related food insecurity during a 1-year period.

RESULTS

We found 10 classes of trajectories of food insecurity, including 1 class of consistent food security (64.7%), 1 class of consistent food insecurity (3.4%), 5 classes of decreasing food insecurity (15.8%), 2 classes of increasing food insecurity (4.6%), and 1 class of stable but elevated food insecurity (11.6%). Relative to the class that remained food secure, other classes were younger, had a greater proportion of women, and tended to identify with a racial or ethnic minority group.

CONCLUSION

We found heterogeneous longitudinal patterns in the development, resolution, or persistence of food insecurity during the first year of the COVID-19 pandemic. Experiences of food insecurity were highly variable across the US population, with one-third experiencing some form of food insecurity risk. Findings have implications for identifying population groups who are at increased risk of food insecurity and related health disparities beyond the first year of the pandemic.

Evaluation of High-Deductible Health Plans and Acute Glycemic Complications Among Adults With Diabetes

Importance

Optimal diabetes care requires regular monitoring and care to maintain glycemic control. How high-deductible health plans (HDHPs), which reduce overall spending but may impede care by increasing out-of-pocket expenses, are associated with risks of severe hypoglycemia and hyperglycemia is unknown.

Objective

To examine the association between an employer-forced switch to HDHP and severe hypoglycemia and hyperglycemia.

Design, Setting, and Participants

This retrospective cohort study used deidentified administrative claims data for privately insured adults with diabetes from a single insurance carrier with multiple plans across the US between January 1, 2010, and December 31, 2018. Analyses were conducted between May 15, 2020, and November 3, 2022.

Exposures

Patients with 1 baseline year of enrollment in a non-HDHP whose employers subsequently forced a switch to an HDHP were compared with patients who did not switch.

Main Outcomes and Measures

Mixed-effects logistic regression models were used to examine the association between switching to an HDHP and the odds of severe hypoglycemia and hyperglycemia (ascertained using diagnosis codes in emergency department [ED] visits and hospitalizations), adjusting for patient age, sex, race and ethnicity, region, income, comorbidities, glucose-lowering medications, baseline ED and hospital visits for hypoglycemia and hyperglycemia, and baseline deductible amount, and applying inverse propensity score weighting to account for potential treatment selection bias.

Results

The study population was composed of 42 326 patients who switched to an HDHP (mean [SD] age: 52 [10] years, 19 752 [46.7%] women, 7375 [17.4%] Black, 5740 [13.6%] Hispanic, 26 572 [62.8%] non-Hispanic White) and 202 729 patients who did not switch (mean [SD] age, 53 [10] years, 89 828 [44.3%] women, 29 551 [14.6%] Black, 26 689 [13.2%] Hispanic, 130 843 [64.5%] non-Hispanic White). When comparing all study years, switching to an HDHP was not associated with increased odds of experiencing at least 1 hypoglycemia-related ED visit or hospitalization (OR, 1.01 [95% CI, 0.95-1.06]; P = .85), but each year of HDHP enrollment did increase these odds by 2% (OR, 1.02 [95% CI, 1.00-1.04]; P = .04). In contrast, switching to an HDHP did significantly increase the odds of experiencing at least 1 hyperglycemia-related ED visit or hospitalization (OR, 1.25 [95% CI, 1.11-1.42]; P < .001), with each year of HDHP enrollment increasing the odds by 5% (OR, 1.05 [95% CI, 1.01-1.09]; P = .02).

Conclusions and Relevance

In this cohort study, employer-forced switching to an HDHP was associated with increased odds of potentially preventable acute diabetes complications, potentially because of delayed or deferred care. These findings suggest that employers should be more judicious in their health plan offerings, and health plans and policy makers should consider allowing preventive and high-value services to be exempt from deductible requirements.

Integrating Produce Prescriptions into the Healthcare System: Perspectives from Key Stakeholders

People with low incomes suffer disproportionately from diet-related chronic diseases and may have fewer resources to manage their diseases. The "food as medicine" movement encourages healthcare systems to address these inequities while controlling escalating healthcare costs by integrating interventions such as produce prescriptions, in which healthcare providers distribute benefits for fruit and vegetable purchases. The purpose of this study was to identify perceived facilitators and barriers for designing and implementing produce prescriptions within the healthcare system. Nineteen semi-structured in-depth interviews were conducted with experts, and interviews were analyzed using thematic analysis. Overall, interviewees perceived that produce prescriptions could impact patients' diets, food security, disease management, and engagement with the healthcare system, while reducing healthcare costs. Making produce prescriptions convenient to use for patients, while providing resources to program implementers and balancing the priorities of payers, will facilitate program implementation. Integrating produce prescriptions into the healthcare system is feasible but requires program administrators to address implementation barriers such as cost and align complex technology systems (i.e., electronic medical records and benefit/payment processing). Engaging patients, clinics, retailers, and payers in the design phase can improve patient experience with a produce-prescription program; enhance clinic and retail processes enrolling patients and redeeming benefits; and ensure payers can measure outcomes of interest.

Strengthening Food and Nutrition Security to Promote Public Health in the United States: A Position Paper From the American College of Physicians

Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.

Dasiglucagon demonstrates reduced costs in the treatment of severe hypoglycemia in a budget impact model

BACKGROUND: Approximately 7.3 million people with type 1 or type 2 diabetes (T1D/T2D) are treated with insulin, placing them at higher risk of severe hypoglycemia (SH). SH requires assistance of another individual and often necessitates the prompt administration of intravenous glucose, injectable glucagon, or both. Untreated, SH can progress to unconsciousness, seizures, coma, or death. Before 2018, all glucagon rescue treatments required reconstitution. The complexity of reconstitution is often a barrier to successful administration during a severe hypoglycemic event. Studies suggest successful administration of glucagon emergency kits range from 6%-56% of the time. Second-generation glucagon treatments and glucagon analogs do not require reconstitution and have caregiver administration success rates ranging from 94%-100%. Dasiglucagon is a glucagon analog administered via autoinjector or prefilled syringe and has been shown to result in rapid hypoglycemia recovery. Moreover, the autoinjector can be administered successfully 94% of the time by trained caregivers. Previous evaluation of costs in budget impact models (BIMs) demonstrated the potential for second-generation glucagon treatments to reduce the cost of SH events (SHEs). The current model expands on those findings with a treatment pathway and accompanying assumptions reflecting important aspects of real-world SHE treatment. OBJECTIVE: To evaluate the economic impact of dasiglucagon compared with available glucagon treatments for SHE management, considering direct cost of treatment and health care resource utilization. METHODS: A 1-year BIM with a hypothetical US commercial health plan of 1 million lives was developed with a target population of individuals with diabetes at risk of SHE. The treatment pathway model included initial and secondary treatment attempts, treatment administration success and failure, plasma glucose (PG) recovery within 15 minutes, emergency medical services, emergency department (ED) visits, and hospitalizations. A 1-way sensitivity analysis was conducted to assess the sensitivity of the model to changes in parameter values. RESULTS: In a 1 million-covered lives population, it was estimated that 12,006 SHEs would occur annually. The higher rate of initial treatment success and PG recovery within 15 minutes associated with dasiglucagon treatment resulted in lower total health care costs. Total SHE treatment costs with dasiglucagon were estimated at $13.4 million, compared with $16.7 million for injectable native glucagon, $20.7 million for nasal glucagon, $35.3 million for reconstituted glucagon, and $43.8 million for untreated individuals. Compared with untreated people, the number needed to treat (NNT) with dasiglucagon was 6 individuals to avoid 1 hospitalization. NNT for this same comparison was 59 for injectable native glucagon and 27 for nasal glucagon. CONCLUSIONS: Treatment of SH with dasiglucagon decreased total direct medical costs by reducing health care resource utilization (emergency calls, emergency transports, ED visits, and hospitalizations) and accompanying costs associated with the treatment of SH. DISCLOSURES: This research was funded by Zealand Pharma. Bromley, Hinahara, and Goss are employed by Boston Healthcare Associates, Inc., which received funding from Zealand Pharma for development of the health economic model and the manuscript. Kendall and Hammer are employed by Zealand Pharma. Weinzimer has received consulting fees from Zealand Pharma.

Assessment of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Code Assignment Validity for Case Finding of Medication-related Hypoglycemia Acute Care Visits Among Medicare Beneficiaries

OBJECTIVE

Administrative claims are commonly relied upon to identify hypoglycemia. We assessed validity of 14 International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code assignments to identify medication-related hypoglycemia leading to acute care encounters.

RESEARCH DESIGN AND METHODS

A multisite, retrospective medical record review study was conducted in a sample of Medicare beneficiaries prescribed outpatient diabetes medications and who received hospital care between January 1, 2016 and September 30, 2017. Diagnosis codes were validated with structured medical record review using prespecified criteria (clinical presentation, blood glucose values, and treatments for hypoglycemia). Sensitivity, specificity, and positive and negative predictive value (PPV, NPV) were calculated and adjusted using sampling weights to correct for partial verification bias.

RESULTS

Among 990 encounters (496 cases, 494 controls), hypoglycemia codes demonstrated moderate PPV (69.2%; 95% confidence interval: 65.0-73.0) and moderate sensitivity (83.9%; 95% confidence interval: 70.0-95.5). Codes performed better at identifying hypoglycemic events among emergency department/observation encounters compared with hospitalizations (PPV 92.9%, sensitivity 100.0% vs. PPV 53.7%, sensitivity 71.0%). Accuracy varied by diagnosis position, especially for hospitalizations, with PPV of 95.6% versus 46.5% with hypoglycemia in primary versus secondary positions. Use of adverse event/poisoning codes did not improve accuracy; reliance on these codes alone would have missed 97% of true hypoglycemic events.

CONCLUSIONS

Accuracy of International Classification of Diseases, Tenth Revision codes in administrative claims to identify medication-related hypoglycemia varied substantially by encounter type and diagnosis position. Consideration should be given to the trade-off between PPV and sensitivity when selecting codes, encounter types, and diagnosis positions to identify hypoglycemia.

Executive summary of the 2021 SAEM consensus conference: From bedside to policy: Advancing social emergency medicine and population health through research, collaboration, and education

BACKGROUND

Social emergency medicine (social EM) examines the intersection of emergency care and the social factors that influence health outcomes. In 2021, the SAEM consensus conference focused on social EM and population health, with the goal of prioritizing research topics, creating collaborations, and advancing the field of social EM.

METHODS

Organization of the conference began in 2019 within SAEM. Cochairs were identified and a planning committee created the framework for the conference. Leaders for subgroups were identified, and subgroups performed literature reviews and identified additional stakeholders within EM and community organizations. As a result of the COVID-19 pandemic, the conference format was modified.

RESULTS

A total of 246 participants registered for the conference and participated in some capacity at three distinct online sessions. Research prioritization subgroups were as follows-group 1: ED screening and referral for social and access needs; group 2: structural competency; and group 3: race, racism, and antiracism. Thirty-two "projects in progress" were presented within five domains-identity and health: people and places; health care systems; training and education; material needs; and individual and structural violence.

CONCLUSIONS

Despite ongoing challenges posed by the COVID-19 pandemic, the 2021 SAEM consensus conference brought together hundreds of stakeholders to define research priorities and create collaborations to push the field forward.

Accessibility of Low-cost Insulin From Illegitimate Internet Pharmacies: Cross-sectional Study

Background

There is much public debate regarding the high cost of insulin. With 1-in-4 patients in the United States with type 1 diabetes reporting difficulties affording insulin, there is concern that some of these patients might look for cost savings on the internet, unaware that 96% of internet pharmacies are illegitimate. Patients who purchase insulin from illegitimate internet pharmacies remove themselves from traditional health care systems that ensure safe, quality-assured, and effective medication use.

Objective

This study aims to determine the accessibility of Humalog and NovoLog insulin from internet pharmacies and characterize how these sites approached patient safety, and priced as well as marketed their products.

Methods

From September to December 2019, we queried the phrases buy insulin online, buy Humalog online, and buy NovoLog online in common search engines. The first 100 search results from Google and Bing, and the first 50 search results from Yahoo! and DuckDuckGo were screened. Websites were included if they claimed to sell Humalog or NovoLog insulin, were active, free access, in the English language, and had a unique URL. The legitimacy of websites was classified using LegitScript. Safety and marketing characteristics were compared across the legitimacy of internet pharmacies. Internet pharmacy prices were compared with the prices offered through brick-and-mortar pharmacies using GoodRx.

Results

We found that 59% (n=29) of the 49 internet pharmacies in our analysis were illegitimate, whereas only 14% (n=7) were legitimate and 27% (n=13) were unclassified. Across illegitimate internet pharmacies, Humalog and NovoLog insulin were 2 to 5 times cheaper as compared with both legitimate internet pharmacies and brick-and-mortar stores. Risks associated with the use of illegitimate internet pharmacies by American consumers were evident: 57% (8/14) did not require a prescription, 43% (6/14) did not display medication information or warnings, and only 21% (3/14) offered access to purported pharmacists. This included 9 rogue internet pharmacies that sold Humalog and NovoLog insulin within the United States, where 11% (1/9) required a prescription, 11% (1/9) placed quantity limits per purchase, and none offered pharmacist services. Rogue internet pharmacies often offered bulk discounts (11/18, 61%), assured privacy (14/18, 78%), and promoted other products alongside insulin (13/18, 72%). The marketing language of illegitimate internet pharmacies appealed more to quality, safety, and customer service as compared with legitimate sites.

Conclusions

The ease of access to low-cost insulin through illegitimate internet pharmacies calls for urgent attention. Illegitimate internet pharmacies place patients at risk of poor-quality medications and subpar pharmacy services, resulting in adverse events and poor diabetes control. A multifaceted approach is needed to close illegitimate internet pharmacies through legal and regulatory measures, develop better search engine filters, raise public awareness of the dangers of illegitimate internet pharmacies, and address the high costs of insulin.

Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes

IMPORTANCE

Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown.

OBJECTIVE

To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021.

EXPOSURES

Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation).

MAIN OUTCOMES AND MEASURES

The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county.

RESULTS

The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049).

CONCLUSIONS AND RELEVANCE

This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.

SNAP participation and the health and health care utilisation of low-income adults and children

OBJECTIVE

This article examined whether participation in the Supplemental Nutrition Assistance Program (SNAP) produced changes to adult and child health and health care utilisation during a period of economic recession.

DESIGN

Instrumental variables analysis relying on variation in state SNAP policies to isolate exogenous variation in household SNAP participation.

SETTING

Nationally representative data on child and adult health from the 2008 to 2013 National Health Interview Survey.

PARTICIPANTS

Participants were 92 237 adults and 45 469 children who were either eligible for SNAP based on household income and state eligibility rules or were low income but not eligible for SNAP benefits.

RESULTS

For adults, SNAP participation increased the probability of reporting very good or excellent health, and for both adults and children, reduced needing but having to go without dental care or eyeglasses. The size of these benefits was especially pronounced for children. However, SNAP participation increased the probability of needing but not being able to afford prescription medicine, and increased psychological distress for adults and behavioural problems for children under age 10.

CONCLUSIONS

SNAP's benefits for adult health and improved access to dental and vision care for adults and children suggest benefits from the program's expansions during the current COVID-induced crisis. Predicted negative effects of SNAP participation suggest the need for attention to program and benefit structure to avoid harm and the need for continued research to explore the causal effects of program participation.

Qualitative analysis of reasons for hospitalization for severe hypoglycemia among older adults with diabetes

BACKGROUND

Hospital admissions for severe hypoglycemia are associated with significant healthcare costs, decreased quality of life, and increased morbidity and mortality, especially for older adults with diabetes. Understanding the reasons for hypoglycemia hospitalization is essential for the development of effective interventions; yet, the causes and precipitants of hypoglycemia are not well understood.

METHODS

We conducted a qualitative study of non-nursing home patients aged 65 years or older without cognitive dysfunction admitted to a single tertiary-referral hospital with diabetes-related hypoglycemia. During the hospitalization, we conducted one-on-one, in-depth, semi-structured interviews to explore: (1) experiences with diabetes management among patients hospitalized for severe hypoglycemia; and (2) factors contributing and leading to the hypoglycemic event. Major themes and sub-themes were extracted using the constant comparative method by 3 study authors.

RESULTS

Among the 17 participants interviewed, the mean age was 78.9 years of age, 76.5% were female, 64.7% African American, 64.7% on insulin, and patients had an average of 13 chronic conditions. Patients reported: (1) surprise at hypoglycemia despite living with diabetes for many years; (2) adequate support, knowledge, and preparedness for hypoglycemia; (3) challenges balancing a diet that minimizes hyperglycemia and prevents hypoglycemia; (4) the belief that hyperglycemia necessitates medical intervention, but hypoglycemia does not; and (5) tension between clinician-prescribed treatment plans and self-management based on patients' experience. Notably, participants did not report the previously cited reasons for hypoglycemia, such as food insecurity, lack of support or knowledge, or treatment errors.

CONCLUSIONS

Our findings suggest that some hypoglycemic events may not be preventable, but in order to reduce the risk of hypoglycemia in older individuals at risk: (1) healthcare systems need to shift from their general emphasis on the avoidance of hyperglycemia towards the prevention of hypoglycemia; and (2) clinicians and patients need to work together to design treatment regimens that fit within patient capacity and are flexible enough to accommodate life's demands.

Financial hardship among cancer survivors in Southern New Jersey

PURPOSE

To identify predictors of financial hardship, operationalized as foregoing health care, making financial sacrifices, and being concerned about having inadequate financial and insurance information.

METHODS

Cancer survivors (n = 346) identified through the New Jersey State Cancer Registry were surveyed from August 2018 to September 2019. Multivariable logistic regression analyses were performed.

RESULTS

Cancer survivors with household incomes less than $50,000 annually were more likely than those earning $50,0000-$90,000 to report foregoing health care (15.8 percentage points, p < 0.05). Compared to retirees, survivors who were currently unemployed, disabled, or were homemakers were more likely to forego doctor's visits (11.4 percentage points, p < 0.05), more likely to report borrowing money (16.1 percentage points, p < 0.01), and more likely to report wanting health insurance information (25.7 percentage points, p < 0.01). Employed survivors were more likely than retirees to forego health care (16.8 percentage points, p < 0.05) and make financial sacrifices (20.0 percentage points, p < 0.01). Survivors who never went to college were 9.8 percentage points (p < 0.05) more likely to borrow money compared to college graduates. Black survivors were more likely to want information about dealing with financial and insurance issues (p < 0.01); men were more likely to forego health care (p < 0.05).

CONCLUSION

Findings highlight the role of employment status and suggest that education, income, race, and gender also shape cancer survivors' experience of financial hardship. There is a need to refine and extend financial navigation programs. For employed survivors, strengthening family leave policies would be desirable.

Associations between shopper impulsivity and cyclical food purchasing: Results from a prospective trial of low-income households receiving monthly benefits

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. Proposed interventions targeting the benefit cycle often focus on impulsive decision-making. However, it remains unclear whether shopper impulsivity is associated with food purchasing behavior. Using data from a prospective trial, we evaluate whether shopper impulsivity is associated with food purchasing behavior before and after households receive nutrition assistance. In this study, 249 low-income households in the Minneapolis-St. Paul, Minnesota, metropolitan area received monthly benefits for three months. Overall impulsivity and impulsivity subtraits of the primary shopper was assessed using the Barratt Impulsiveness Scale-11. Both total food expenditures and expenditures for two specific categories (fruits and vegetables, and foods high in added sugar) were evaluated. Generalized estimating equations were used to model household expenditures as a function of week since benefit distribution, impulsivity, and their interaction. Results showed that during the benefit period, food expenditures were cyclical and patterned by impulsivity. Shoppers with greater overall impulsivity spent $40.62 more in week 1 (p < 0.001). While more impulsive shoppers spent more on foods high in added sugar throughout the month (p < 0.05 for all weeks), no patterns were observed for fruits and vegetables. These findings suggest that greater impulsivity exacerbates cyclical food purchasing behavior. The impact of shopper impulsivity is especially notable for expenditures on foods high in added sugar. SNAP educational interventions to mitigate the benefit cycle may be strengthened by focusing on more impulsive shoppers and on strategies to reduce impulsive purchases of foods high in added sugar.

Screening for Health-Related Social Needs of Emergency Department Patients

STUDY OBJECTIVE

There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs.

METHODS

We analyzed data from the 2018 National Emergency Department Inventory-New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening.

RESULTS

Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability.

CONCLUSION

New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED.

Trends in cyclical food expenditures among low-income households receiving monthly nutrition assistance: results from a prospective study

OBJECTIVE

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics.

DESIGN

Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means.

SETTING

Minneapolis-St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

Low-income households (n 249) enrolled May 2013-August 2015.

RESULTS

Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households.

CONCLUSIONS

Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

Prevalence of Emergency Department Social Risk and Social Needs

Introduction

Social risks, or adverse social conditions associated with poor health, are prevalent in emergency department (ED) patients, but little is known about how the prevalence of social risk compares to a patient’s reported social need, which incorporates patient preference for intervention. The goal of this study was to describe the relationship between social risk and social need, and identify factors associated with differential responses to social risk and social need questions.

Methods

We conducted a cross-sectional study with 48 hours of time-shift sampling in a large urban ED. Consenting patients completed a demographic questionnaire and assessments of social risk and social need. We applied descriptive statistics to the prevalence of social risk and social need, and multivariable logistic regression to assess factors associated with social risk, social need, or both.

Results

Of the 269 participants, 100 (37%) reported social risk, 83 (31%) reported social need, and 169 (63%) reported neither social risk nor social need. Although social risk and social need were significantly associated (p < 0.01), they incompletely overlapped. Over 50% in each category screened positive in more than one domain (eg, housing instability, food insecurity). In multivariable models, those with higher education (adjusted odds ratio [aOR] 0.44 [95% confidence interval {CI}, 0.24–0.80]) and private insurance (aOR 0.50 [95% CI, 0.29–0.88]) were less likely to report social risk compared to those with lower education and state/public insurance, respectively. Spanish-speakers (aOR 4.07 [95% CI, 1.17–14.10]) and non-Hispanic Black patients (aOR 5.00 [95% CI, 1.91–13.12]) were more likely to report social need, while those with private insurance were less likely to report social need (private vs state/public: aOR 0.13 [95% CI, 0.07–0.26]).

Conclusion

Approximately one-third of patients in a large, urban ED screened positive for at least one social risk or social need, with over half in each category reporting risk/need across multiple domains. Different demographic variables were associated with social risk vs social need, suggesting that individuals with social risks differ from those with social needs, and that screening programs should consider including both assessments.

The terminology of social emergency medicine: Measuring social determinants of health, social risk, and social need

Emergency medicine has increasingly focused on addressing social determinants of health (SDoH) in emergency medicine. However, efforts to standardize and evaluate measurement tools and compare results across studies have been limited by the plethora of terms (eg, SDoH, health-related social needs, social risk) and a lack of consensus regarding definitions. Specifically, the social risks of an individual may not align with the social needs of an individual, and this has ramifications for policy, research, risk stratification, and payment and for the measurement of health care quality. With the rise of social emergency medicine (SEM) as a field, there is a need for a simplified and consistent set of definitions. These definitions are important for clinicians screening in the emergency department, for health systems to understand service needs, for epidemiological tracking, and for research data sharing and harmonization. In this article, we propose a conceptual model for considering SDoH measurement and provide clear, actionable, definitions of key terms to increase consistency among clinicians, researchers, and policy makers.

Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes

BACKGROUND

Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations.

OBJECTIVE

The objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants.

RESEARCH DESIGN

Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis.

SUBJECTS

A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare.

MEASURES

Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment.

RESULTS

Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%).

CONCLUSION

A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.

Hunger pains? SNAP timing and emergency room visits

This project uses quasi-random assignment of SNAP receipt dates linked to Medicaid healthcare records to examine whether ER use is affected by the timing of benefits. We find an increase in ER usage at the end of the benefit month, but only among older recipients. The estimated effect is much larger when the end of the benefit cycle coincides with the end of the calendar month, which is when other transfer payments are also depleted. This suggests that within this older group, increased food insecurity leads to increased ER utilization. Further, we find that the share of ER visitors that received SNAP benefits on the day of their ER visit is 3.1% lower than in the SNAP population. This is consistent with benefit receipt altering household behaviors and routines (notably, we observe, by increasing shopping), which may crowd out healthcare utilization. This particular effect is present across all age groups, although the magnitude is smallest for children.

Incorporating machine learning and social determinants of health indicators into prospective risk adjustment for health plan payments

BACKGROUND

Risk adjustment models are employed to prevent adverse selection, anticipate budgetary reserve needs, and offer care management services to high-risk individuals. We aimed to address two unknowns about risk adjustment: whether machine learning (ML) and inclusion of social determinants of health (SDH) indicators improve prospective risk adjustment for health plan payments.

METHODS

We employed a 2-by-2 factorial design comparing: (i) linear regression versus ML (gradient boosting) and (ii) demographics and diagnostic codes alone, versus additional ZIP code-level SDH indicators. Healthcare claims from privately-insured US adults (2016-2017), and Census data were used for analysis. Data from 1.02 million adults were used for derivation, and data from 0.26 million to assess performance. Model performance was measured using coefficient of determination (R²), discrimination (C-statistic), and mean absolute error (MAE) for the overall population, and predictive ratio and net compensation for vulnerable subgroups. We provide 95% confidence intervals (CI) around each performance measure.

RESULTS

Linear regression without SDH indicators achieved moderate determination (R² 0.327, 95% CI: 0.300, 0.353), error ($6992; 95% CI: $6889, $7094), and discrimination (C-statistic 0.703; 95% CI: 0.701, 0.705). ML without SDH indicators improved all metrics (R² 0.388; 95% CI: 0.357, 0.420; error $6637; 95% CI: $6539, $6735; C-statistic 0.717; 95% CI: 0.715, 0.718), reducing misestimation of cost by $3.5 M per 10,000 members. Among people living in areas with high poverty, high wealth inequality, or high prevalence of uninsured, SDH indicators reduced underestimation of cost, improving the predictive ratio by 3% (~$200/person/year).

CONCLUSIONS

ML improved risk adjustment models and the incorporation of SDH indicators reduced underpayment in several vulnerable populations.

Clinician Experiences and Attitudes Regarding Screening for Social Determinants of Health in a Large Integrated Health System

BACKGROUND

Clinical screening for basic social needs-such as food and housing insecurity-is becoming more common as health systems develop programs to address social determinants of health. Clinician attitudes toward such programs are largely unexplored.

OBJECTIVE

To describe the attitudes and experiences of social needs screening among a variety of clinicians and other health care professionals.

RESEARCH DESIGN

Multicenter electronic and paper-based survey.

SUBJECTS

Two hundred fifty-eight clinicians including primarily physicians, social workers, nurses, and pharmacists from a large integrated health system in Southern California.

MEASURES

Level of agreement with prompts exploring attitudes toward and barriers to screening and addressing social needs in different clinical settings.

RESULTS

Overall, most health professionals supported social needs screening in clinical settings (84%). Only a minority (41%) of clinicians expressed confidence in their ability to address social needs, and less than a quarter (23%) routinely screen for social needs currently. Clinicians perceived lack of time to ask (60%) and resources (50%) to address social needs as their most significant barriers. We found differences by health profession in attitudes toward and barriers to screening for social needs, with physicians more likely to cite time constraints as a barrier.

CONCLUSIONS

Clinicians largely support social needs programs, but they also recognize key barriers to their implementation. Health systems interested in implementing social needs programs should consider the clinician perspective around the time and resources required for such programs and address these perceived barriers.

Emerging trends and the clinical impact of food insecurity in patients with diabetes

Food insecurity is a major public health concern in the United States affecting 15 million households according to data in 2017 from the US Department of Agriculture. Food insecurity, or the inability to consistently obtain nutritious food, disproportionately affects socioeconomically disadvantaged households, as well as those with chronic diseases including diabetes mellitus (DM). This review article explores the literature over the past 10 years pertaining to the complex relationship between food insecurity, social determinants of health, and chronic disease with an emphasis on diabetes and glycemic control. Those with diabetes and food insecurity together have been shown to have worse glycemic control compared to those who are food secure, but it remains unclear exactly how food insecurity affects glycemic control. Prior interventional studies have targeted aspects of food insecurity in patients with diabetes but have reported variable outcomes with respect to improvement in glycemic control despite effectively reducing rates of food insecurity. Additionally, few data exist regarding long-term outcomes and diabetes-related complications in this population. It is likely that many factors at both the community and individual levels impact glycemic control outcomes in the setting of food insecurity. Further studies are needed to better understand these factors and to create multifaceted targets for future interventional studies aimed at improving glycemic control in this population.

The assessment and management of quality of life of older adults with diabetes mellitus

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

Food Insecurity May Be an Independent Risk Factor Associated with Nonalcoholic Fatty Liver Disease among Low-Income Adults in the United States

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD), considered a "barometer" of metabolic health, is the leading cause of liver disease in the United States. Despite established associations between food insecurity and obesity, hypertension, and diabetes, little is known about the relation between food insecurity and NAFLD.

OBJECTIVE

We sought to evaluate the association of food insecurity with NAFLD among low-income adults in the United States.

METHODS

We conducted a cross-sectional analysis of a nationally representative sample of adults from the NHANES (2005-2014 waves). Participants included adults in low-income households (≤200% of the federal poverty level) without chronic viral hepatitis or self-reported heavy alcohol use. Food insecurity was measured using the Household Food Security Survey. Our primary outcome was NAFLD, as estimated by the US Fatty Liver Index, and our secondary outcome was advanced fibrosis, as estimated by the NAFLD fibrosis score. The association between food insecurity (defined as low and very low food security) and hepatic outcomes was assessed using multivariable logistic regression, adjusting for sociodemographic factors.

RESULTS

Among 2627 adults included in the analysis, 29% (95% CI: 26%, 32%) were food insecure. The median age was 43 y, 58% were female, and 54% were white. The weighted estimated prevalence of NAFLD did not differ significantly by food security status (food secure 31% compared with food insecure 34%, P = 0.21). In the multivariable model, food-insecure adults were more likely to have NAFLD (adjusted OR: 1.38; 95% CI: 1.08, 1.77) and advanced fibrosis (adjusted OR: 2.20; 95% CI: 1.27, 3.82) compared with food-secure adults.

CONCLUSIONS

Food insecurity may be independently associated with NAFLD and advanced fibrosis among low-income adults in the United States. Future strategies should assess whether improved food access, quality, and healthy eating habits will decrease the growing burden of NAFLD-associated morbidity and mortality among at-risk adults.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

INTRODUCTION

Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

METHODS

This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

RESULTS

Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

CONCLUSIONS

A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Supermarket Purchases Over the Supplemental Nutrition Assistance Program Benefit Month: A Comparison Between Participants and Nonparticipants

INTRODUCTION

The Supplemental Nutrition Assistance Program provides financial assistance for food and beverage purchases to approximately 1 in 7 Americans, with benefits distributed once monthly. Most Supplemental Nutrition Assistance Program benefits are spent early in the month, leading to decreased caloric intake later in the month. The effects of this early benefit depletion on the types of foods and beverages purchased over the course of the month is unclear.

METHODS

Using individually tracked sales data from 950 participants enrolled in 2 supermarket-based RCTs in Maine (October 2015-April 2016 and October 2016-June 2017), purchases of selected food categories by Supplemental Nutrition Assistance Program participants (n=248) versus nonparticipants (n=702) in the first 2 weeks compared with the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month were examined. Analyses were completed in 2019.

RESULTS

For Supplemental Nutrition Assistance Program participants, adjusted mean food spending decreased 37% from the first 2 weeks to the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month (p<0.0001) compared with a 3% decrease (p=0.02) for nonparticipants. The decline in spending by Supplemental Nutrition Assistance Program participants occurred in all examined categories: vegetables (-25%), fruits (-27%), sugar-sweetened beverages (-30%), red meat (-37%), convenience foods (-40%), and poultry (-48%). Difference-in-difference estimators comparing Supplemental Nutrition Assistance Program participants with nonparticipants were statistically significant (p<0.05) for all examined categories.

CONCLUSIONS

In the second half of the Supplemental Nutrition Assistance Program benefit month, individuals reduced purchases of all examined categories. More research is needed to understand the impact of these fluctuations in spending patterns on the dietary quality of Supplemental Nutrition Assistance Program participants.

Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals

IMPORTANCE

Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.

OBJECTIVE

To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.

EXPOSURES

Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.

MAIN OUTCOMES AND MEASURES

The incidence of out-of-network billing and the potential amount of patients' financial liability associated with out-of-network bills from the admission or visit.

RESULTS

Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P < .001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001).

CONCLUSIONS AND RELEVANCE

Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.

Alternatives to SNAP: Global Approaches to Addressing Childhood Poverty and Food Insecurity

The Supplemental Nutrition Assistance Program (SNAP) in the United States is a key element of the nation's safety net. Yet, 12.5 million US children live in households that experience food insecurity, despite national spending of $65 billion on SNAP alone.In analyses integrating data from the 36 Organisation for Economic Co-operation and Development (OECD) countries, we found that child poverty and food insecurity are much higher in the United States than in most of the other OECD countries. The United States has higher total social spending than other OECD countries, but a lower rate of spending on children and families. This international comparison suggests that potentially effective solutions implemented in other countries might help further alleviate US childhood poverty and food insecurity.Broadly, we recommend increasing investments in families with children, particularly low-income families. Our specific recommendations include increasing SNAP benefits, establishing additional benefits to support low-income families with young children, and implementing a universal child allowance. Achieving substantial reductions in child poverty and food insecurity will require overcoming many challenges, including the current US political climate, a national history of underinvestment in social programs, a lack of political will, and a culture of structural racism.

SNAP, Young Children's Health, and Family Food Security and Healthcare Access

INTRODUCTION

The Supplemental Nutrition Assistance Program (SNAP) is the largest nutrition assistance program in the U.S. This study's objective was to examine the associations between SNAP participation and young children's health and development, caregiver health, and family economic hardships.

METHODS

Cross-sectional data from 2006 to 2016 were analyzed in 2017 for families with children aged <3 years in 5 cities. Generalized estimating equations and logistic regression were used to evaluate the associations of SNAP participation with child and caregiver health outcomes and food insecurity, forgone health care, and health cost sacrifices. Nonparticipants that were likely to be eligible for SNAP were compared with SNAP participants and analyses adjusted for covariates including Consumer Price Index for food to control for site-specific food prices.

RESULTS

The adjusted odds of fair or poor child health status (AOR=0.92, 95% CI=0.86, 0.98), developmental risk (AOR=0.82, 95% CI=0.69, 0.96), underweight, and obesity in children were lower among SNAP participants than among nonparticipants. In addition, food insecurity in households and among children, and health cost sacrifices were lower among SNAP participants than among nonparticipants.

CONCLUSIONS

Participation in SNAP is associated with reduced household and child food insecurity, lower odds of poor health and growth and developmental risk among infants and toddlers, and reduced hardships because of healthcare costs for their families. Improved SNAP participation and increased SNAP benefits that match the regional cost of food may be effective preventive health strategies for promoting the well-being of families with young children.

Nasal Glucagon Versus Injectable Glucagon for Severe Hypoglycemia: A Cost-Offset and Budget Impact Analysis

BACKGROUND

Severe hypoglycemic events (SHEs) in patients with diabetes are associated with substantial health care costs in the United States (US). Injectable glucagon (IG) is currently available for treatment of severe hypoglycemia but is associated with frequent handling errors. Nasal glucagon (NG) is a novel, easier-to-use treatment that is more often administered successfully. The economic impact of this usability advantage was explored in cost-offset and budget impact analyses for the US setting.

METHODS

A health economic model was developed to estimate mean costs per SHE for which treatment was attempted using NG or IG, which differed only in the probability of treatment success, based on a published usability study. The budget impact of NG was projected over 2 years for patients with type 1 diabetes (T1D) and type 2 diabetes treated with basal-bolus insulin (T2D-BB). Epidemiologic and cost data were sourced from the literature and/or fee schedules.

RESULTS

Mean costs were $992 lower if NG was used compared with IG per SHE for which a user attempted treatment. NG was estimated to reduce SHE-related spending by $1.1 million and $230 000 over 2 years in 10 000 patients each with T1D and T2D-BB, respectively. Reduced spending resulted from reduced professional emergency services utilization as successful treatment was more likely with NG.

CONCLUSIONS

The usability advantage of NG over IG was projected to reduce SHE-related treatment costs in the US setting. NG has the potential to improve hypoglycemia emergency care and reduce SHE-related treatment costs.

Ability to Reach Low-Income Smokers Enrolled in a Randomised Controlled Trial Varies with Time of Month

Introduction

Because of financial pressures, low-income individuals sometimes run out of cellphone service towards the end of the month.

Aims

To determine if the time of month affects ability to reach low-income smokers by telephone.

Methods

We reviewed data from a completed trial in the United States of emergency department (ED)-initiated tobacco dependence treatment for low-income smokers at a busy, academic ED in an urban community. We recorded the date of each one-month follow-up call, and divided each month into four time blocks: Week 1, Week 2, Week 3, and Week 4.

Results

A total of 2,049 phone calls were made to reach 769 participants. Of these calls, 677 (33%) resulted in contact; 88% of all participants were contacted. Using generalised estimating equations with Week 4 as reference, the odds of a successful contact at Weeks 1, 2, and 3 were, respectively, 1.52 (95% CI 1.18, 1.96), 1.30 (95% CI 1.01, 1.66), and 1.37 (95% CI 1.07, 1.76).

Conclusions

Study participants became progressively difficult to reach. This result may reflect low-income smokers' decreased rates of active telephone service later in the month and suggests a mechanism to improve follow-up rates in future studies of low-income populations.

Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature

PURPOSE

The primary purpose of this study is to report a systematic review of evidence and gaps in the literature among well-conducted studies assessing the impact of diabetes education on hypoglycemia outcomes and secondarily reporting the impact on other included target outcomes.

METHODS

The authors used a modified Cochrane method to systematically search and review English-language titles, abstracts, and full-text articles published in the United States between January 2001 and December 2017, with diabetes education specified as an intervention and a directly measurable outcome for hypoglycemia risk or events included.

RESULTS

Fourteen quasi-experimental, experimental, and case-control studies met the inclusion criteria, with 8 articles reporting a positive impact of diabetes self-management education and support (DSMES) on hypoglycemia outcomes; 2 of the 8 reported decreased hypoglycemia events, and 1 reported decreased events in both the intervention and control groups. In addition, 5 studies targeted change in reported hypoglycemia symptoms, with all 5 reporting a significant decrease. DSMES also demonstrated an impact on intermediate (knowledge gain, behavior change) and long-term (humanistic and economic/utilization) outcomes. An absence of common hypoglycemia measures and terminology and suboptimal descriptions of DSMES programs for content, delivery, duration, practitioner types, and participants were identified as gaps in the literature.

CONCLUSIONS

Most retained studies reported that diabetes education positively affected varied measures of hypoglycemia outcomes (number of events, reported symptoms) as well as other targeted outcomes. Diabetes education is an important intervention for reducing hypoglycemia events and/or symptoms and should be included as a component of future hypoglycemia risk mitigation studies.

The longitudinal relationship between food insecurity in older adults with diabetes and emergency department visits, hospitalizations, hemoglobin A1c, and medication adherence

AIMS

To examine the relationship between food insecurity and emergency department (ED) visits, hospitalizations, A1c, and diabetes medication adherence over one year of follow-up among individuals >65 years with diabetes mellitus.

METHODS

We conducted a longitudinal cohort study of adults >65 years with diabetes who did (n = 742) or did not (n = 2226) report food insecurity at baseline. We used conditional logistic regression for the ED visits or hospitalization outcomes, and mixed effects models for A1c and non-insulin diabetes medication adherence.

RESULTS

In bivariate analyses, individuals with food insecurity were more likely to have an ED visit (OR = 1.40, 95% CI 1.15-1.72) or hospitalization (OR = 1.41, 95% CI 1.11-1.78) in the year after the food security assessment. In addition, A1c was higher (7.5% vs. 7.2%, p < 0.001). There was no difference in medication adherence. These differences persisted with adjustment for basic demographic and clinical characteristics, but were attenuated with further adjustment for socioeconomic status.

CONCLUSIONS

Differences in diabetes outcomes by food insecurity status were attenuated by adjustment for socioeconomic status. Adverse outcomes in individuals with diabetes and food insecurity may be driven by effects of food insecurity per se or be mediated by a constellation of basic resource needs or lower socioeconomic status.

Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States

Food insecurity affects 1 in 8 US households and has clear implications for population health disparities. We present a person-centered, multilevel framework for understanding how individuals living in food-insecure households cope with inadequate access to food themselves and within their households, communities, and broader food system. Many of these coping strategies can have an adverse impact on health, particularly when the coping strategies are sustained over time; others may be salutary for health. There exist multiple opportunities for aligning programs and policies so that they simultaneously support food security and improved diet quality in the interest of supporting improved health outcomes. Improved access to these programs and policies may reduce the need to rely on individual- and household-level strategies that may have negative implications for health across the life course.

Medically Tailored Meal Delivery for Diabetes Patients with Food Insecurity: a Randomized Cross-over Trial

BACKGROUND

Food insecurity, defined as inconsistent food access owing to cost, leads to poor health.

OBJECTIVE

To test whether a medically tailored meal delivery program improved dietary quality in individuals with type 2 diabetes and food insecurity.

DESIGN

Randomized cross-over clinical trial.

PARTICIPANTS

Forty-four adults with diabetes, hemoglobin A1c > 8.0%, and food insecurity (defined as at least one positive item on the two-item "Hunger Vital Sign").

INTERVENTION

In the Community Servings: Food as Medicine for Diabetes cross-over clinical trial (NCT02426138), conducted from June 2015 to July 2017, we randomly assigned the order of "on-meals" (home delivery of 10 meals/week for 12 weeks delivered by Community Servings, a non-profit organization) and "off-meals" (12 weeks usual care and a Choose MyPlate healthy eating brochure) periods.

MAIN MEASURES

The primary outcome was Healthy Eating Index 2010 score (HEI), assessed by three 24-h food recalls in both periods. Higher HEI score (range 0-100; clinically significant difference 5) represents better dietary quality. Secondary outcomes included food insecurity and self-reported hypoglycemia.

KEY RESULTS

Mean "on-meal" HEI score was 71.3 (SD 7.5) while mean "off-meal" HEI score was 39.9 (SD 7.8) (difference 31.4 points, p < 0.0001). Participants experienced improvements in almost all sub-categories of HEI score, with increased consumption of vegetables, fruits, and whole grains and decreased solid fats, alcohol, and added sugar consumption. Participants also reported lower food insecurity (42% "on-meal" vs. 62% "off-meal," p = 0.047), less hypoglycemia (47% "on-meal" vs. 64% "off-meal," p = 0.03), and fewer days where mental health interfered with quality of life (5.65 vs. 9.59 days out of 30, p = 0.03).

CONCLUSIONS

For food-insecure individuals with diabetes, medically tailored meals improved dietary quality and food insecurity and reduced hypoglycemia. Longer-term studies should evaluate effects on diabetes control (e.g., hemoglobin A1c) and patient-reported outcomes (e.g., well-being).

The association between hypoglycemia and hospital use, food insufficiency, and unstable housing conditions: a cross-sectional study among patients with type 2 diabetes in Sudan

Objectives

Hypoglycemia is associated with mortality and healthcare utilization. We aimed to assess hypoglycemia risk and Hospital use among Sudanese patients with type 2 diabetes.

Results

One hundred and fifty-nine patients with type 2 diabetes attending a diabetes center in Omdurman, Sudan during the period from June to September 2018were approached. A structured questionnaire based on hypoglycemia risk and Hospital use, Fasting plasma glucose (FPG) and the glycated hemoglobin (HbA_1c) was used to interview the patients. Participants (age 58.13 ± 9.96 years), 4.4%, 14.5%, and 81.1% were at high, moderate, and low hypoglycemia respectively, 66% reported food insufficiency, while 15.1% had unstable housing conditions. No relationship was evident between the hypoglycemia risk, gender, unstable housing conditions, food insufficiency, fasting plasma glucose,HbA_1c, and the duration since the diagnosis of diabetes. A considerable number (18.9%) of Sudanese patients with diabetes were at moderate/high risk of hypoglycemia and Hospital use, including hypoglycemia risk and hospital use assessment in the holistic care of diabetes are recommended.

Association Between Supplemental Nutrition Assistance Program Participation and Cost-Related Medication Nonadherence Among Older Adults With Diabetes

Importance

Understanding if the association of social programs with health care access and utilization, especially among older adults with costly chronic medical conditions, can help in improving strategies for self-management of disease.

Objective

To examine whether participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with a reduced likelihood of low-income older adults with diabetes (aged ≥65 years) needing to forgo medications because of cost.

Design, Setting, and Participants

This repeated cross-sectional, population-based study included 1302 seniors who participated in the National Health Interview Survey from 2013 through 2016. Individuals in the study were diagnosed with diabetes or borderline diabetes, were eligible to receive SNAP benefits, were prescribed medications, and incurred more than zero US dollars in out-of-pocket medical expenses in the past year. The data analysis was performed from October 2017 to April 2018.

Exposures

Self-reported participation in SNAP.

Main Outcomes and Measures

Cost-related medication nonadherence derived from responses to whether in the past year, older adults with diabetes delayed refilling a prescription, took less medication, and skipped medication doses because of cost. To estimate the association between participation in SNAP and cost-related medication nonadherence, we used 2-stage, regression-adjusted propensity score matching, conditional on sociodemographic and health and health care-related characteristics of individuals. Estimated propensity scores were used to create matched groups of participants in SNAP and eligible nonparticipants. After matching, a fully adjusted weighted model that included all covariates plus food security status was used to estimate the association between SNAP and cost-related medication nonadherence in the matched sample.

Results

The final analytic sample before matching included 1385 older adults (448 [32.3%] men, 769 [55.5%] non-Hispanic white, and 628 [45.3%] aged ≥75 years), with 503 of them participating in SNAP (36.3%) and 178 reporting cost-related medication nonadherence (12.9%) in the past year. After matching, 1302 older adults were retained (434 [33.3%] men, 716 [55.0%] non-Hispanic white, and 581 [44.6%] aged ≥75 years); treatment and comparison groups were similar for all characteristics. Participants in SNAP had a moderate decrease in cost-related medication nonadherence compared with eligible nonparticipants (5.3 percentage point reduction; 95% CI, 0.5-10.0 percentage point reduction; P = .03). Similar reductions were observed for subgroups that had prescription drug coverage (5.8 percentage point reduction; 95% CI, 0.6-11.0) and less than $500 in out-of-pocket medical costs in the previous year (6.4 percentage point reduction; 95% CI, 0.8-11.9), but not for older adults lacking prescription coverage or those with higher medical costs. Results remained robust to several sensitivity analyses.

Conclusions and Relevance

The findings suggest that participation in SNAP may help improve adherence to treatment regimens among older adults with diabetes. Connecting these individuals with SNAP may be a feasible strategy for improving health outcomes.