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Addressing unmet resource needs may improve cardiometabolic management

Patients who screened positive for unmet basic resource needs and were enrolled in a program to address those needs showed statistically significant improvements in BP and cholesterol levels, but not blood glucose level, according to recent findings published in JAMA Internal Medicine.

“Chronic cardiometabolic diseases, such as hypertension, diabetes, and lipid disorders, are leading causes of morbidity and mortality in the United States,” Seth A. Berkowitz, MD, MPH, of the division of general internal medicine at Massachusetts General Hospital, and colleagues wrote. “The connection between poor outcomes in these conditions and unmet resource needs, such as difficulty affording food, housing, and medications, has become increasingly clear. This has led to interest in programs that seek to ‘link’ patients identified in clinical care sites as having unmet basic resource needs to community-based resources.”

“Despite growing interest and intuitive appeal, there is as yet scant evidence to support the effectiveness of linkage interventions for improving cardiometabolic disease control,” they added.

Between Oct. 1, 2012 and Sept. 30, 2015, Berkowitz and colleagues conducted a difference-in-difference evaluation of the Health Leads program to determine its effectiveness in improving blood pressure (systolic and diastolic), LDL cholesterol level and hemoglobin A1c (HbA1c) level. The program screens patients for unmet needs, then provides assistance for those who test positive by offering brief information provisions or meetings with an advocate to obtain resources. The evaluation was performed at three academic primary care practices in the Boston metropolitan area. The researchers compared changes in systolic BP, diastolic BP, LDL cholesterol level and HbA1c level between patients who did and did not screen positive, as well as between those who did and did not enroll in Health Leads, using intention-to-treat and linear mixed modeling, respectively.

Berkowitz and colleagues screened 5,125 patients for unmet basic resource needs, of whom 1,774 screened positive (mean age, 57.6 years; 56% women), and 3,351 screened negative (mean age, 56.7 years; 57% women). Among the 1,774 patients who reported at least one unmet need, 58% (n = 1,021) enrolled in Health Leads. Follow-up was performed at a median of 34 and 32 months for patients who screened positive and negative, respectively.

An unadjusted intention-to-treat analysis revealed that a greater decline in systolic BP (differential change, −1.2 mm Hg; 95%CI, −2.1 to −0.4) and diastolic BP (differential change, −1 mm Hg; 95% CI, −1.5 to −0.5) was observed in patients with hypertension  in the Health Leads group than those who screened negative. Similarly, patients with an indication for LDL cholesterol level lowering in the Health Leads group showed more improvement in LDL cholesterol levels (differential change, −3.7 mg/dL; 95% CI −6.7 to −0.6). Conversely, HbA1c levels did not improve among patients with diabetes in the Health Leads group (differential change, −0.04%; 95% CI, −0.17 to 0.10).

Furthermore, compared with patients who opted not to enroll in Health Leads, those who did enroll experienced more improvements in systolic BP (differential change −2.6 mm Hg; 95% CI, −3.5 to −1.7) diastolic BP (differential change, −1.4 mm Hg; 95% CI, −1.9 to −0.9) and LDL cholesterol level (differential change, −6.3 mg/dL; 95% CI, −9.7 to −2.8).

“An unanswered question resulting from this study is why BP and LDL [cholesterol] level improved while HbA1c level did not. At this time, we are not sure why we observed this,” Berkowitz and colleagues wrote. “The data in this study suggest that connections to resources to meet various needs (eg, medication affordability and food) occur with equal success. However, the result of that connection may vary depending on the adequacy and efficacy of the resource landscape available.”

The researchers reported that results did not qualitatively differ when adjusted for baseline demographic and clinical differences.

Further refining and disseminating intervention programs that screen for unmet basic needs and offer patients with such needs access to community resources have the potential to enhance the health of susceptible populations, Berkowitz and colleagues concluded.

In a related editorial, Ashley M. McMullen, MD, of the department of internal medicine at the University of California, San Francisco, and Mitchell H. Katz, MD, of the Los Angeles County Department of Health Services, suggest that the study points to vital unanswered questions: Who should clinicians be screening for unmet needs and how?

In addition, they argue that addressing unmet needs is a “work around.” According to McMullen and Katz, “the underlying question is how do we ameliorate the social inequalities that allow health disparities to exist in the first place. It is imperative that we recognize how structural barriers … result in disparate health outcomes. Thus, as we work toward addressing the unmet needs of our individual patients, we also have a role to play in supporting reform policies and systems change in order to address the greater need for social justice in our society.” – by Alaina Tedesco

Disclosure: Berkowitz reports receiving support from Massachusetts General Hospital. McMullen and Katz do not report any relevant financial disclosures.