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With guidelines and best practice recommendations, the treatment / management plans focus on achieving laboratory goals and physical parameters for improved outcomes. While targeting hemoglobin A1c and blood pressure values are important as potential determinants of morbidity and mortality risk, optimizing these parameters only addresses some of the factors that are relevant to different endpoints.
In a previous edition, Ozieh et al. examined the individual and cumulative effects of social health determinants (depression, food insecurity, poverty) on the overall mortality of 1,376 people with diabetes and chronic kidney disease. Social determinants of health were significantly linked to mortality, even with adjustments for demographics, lifestyle variables, glycemic control, and comorbidities. Depression was independently associated with mortality. People with all 3 areas had a 41% higher risk of death. Health care providers have recognized that socioeconomic factors affect health in terms of access to health care, health literacy, and adherence, but the magnitude of the impact has been underestimated.
With the challenge of cluttered office / clinic schedules and numerous competing health conditions that require assessment, the opportunity to invest time in understanding a patient’s economic situation or the features of a patient’s life is not often available. Doctors may limit the ability to treat patients without this information. This understanding would serve to strengthen the provider-patient relationship. Perhaps the initial assessment approach for the treatment of diabetes, chronic kidney disease, or high blood pressure would include questions about assessing food insecurity, ability to maintain a certain diet, or ability to meet deadlines, the generally incorrect assumptions that a person makes failure to follow prescribed treatment is due to a lack of care on the part of the patient.
In recent years, newer drugs such as SGLT-2 inhibitors have been introduced to treat diabetes with the promise of improved cardiac and renal outcomes. These agents are often expensive and it is often difficult to obtain insurance coverage. As research and pharmaceutical development continue to offer us newer treatment options, we must keep in mind that treating the biochemical parameters with therapeutics alone will not fully address the health effects of many of our chronic diseases. We need to advocate investment in case management and social interventions at the same time.
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