Can adverse economic circumstances have a negative impact in the glycemic control of patients with diabetes?

Can adverse economic circumstances have a negative impact in the glycemic control of patients with diabetes? Mounting evidence suggests that this may be the case (1, 2). A recently published cross-sectional study identified food insecurity and cost-related medication underuse as unmet basic needs that were independently associated with poor diabetes control (1). Although associations between diabetes-related complications (e.g., lower extremity amputations or acute cardiovascular events) and specific material need insecurities were not investigated in this study, the data presented by Berkowitz and collaborators suggests that patients with diabetes struggling with financial burdens could be particularly vulnerable to this disease and may need a higher use of health care resources (1). Clearly, there are no simple solutions for these social problems that require the implementation of population-based strategies that go well beyond the scope and limits of public health. So, what can we do as clinicians? Certainly activism to end poverty, build prosperity, and advocate for universal health coverage would be welcomed. Also, we can recognize that the principles of minimally disruptive medicine offer opportunities that are particularly valuable in populations with limited financial capacity. Excessively demanding treatment plans in patients with diabetes and other associated chronic comorbidities – that include the use of multiple costly medications and unnecessarily investigations – can lead to the disruption of patients’ wellbeing, poor treatment adherence, and eventually the development of negative outcomes (3). In patients struggling with material need insecurities we should expect some limitations in their capacity, and therefore, it is in this group that health care should be the least disruptive as possible.

Oscar L. Morey-Vargas MD
Endocrinology, Diabetes, and Nutrition Fellow
Mayo Clinic, Rochester

References

  1. Berkowitz SA, Meigs JB, DeWalt D, Seligman HK, Barnard LS, Bright OM, Schow M, Atlas SJ, Wexler DJ. Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources: Results of the Measuring Economic Insecurity in Diabetes JAMA Intern Med. 2014 Dec 29. doi: 10.1001/jamainternmed.2014.6888.
  2. Ngo-Metzger Q, Sorkin DH, Billimek J, Greenfield S, Kaplan SH. The effects of financial pressures on adherence and glucose control among racial/ethnically diverse patients with diabetes. J Gen Intern Med. 2012;27(4):432-437.
  3. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ. 2009 Aug 11;339:b2803. doi: 10.1136/bmj.b2803.

The Caregiver Corps – let’s do it!

Caregiver Corps: Tapping A Nation of Caring People

By Janice Lynch Schuster

I recently participated in a Twitterchat (#eldercarechat), where someone raised the question of what we want government to do to improve the lives of the nation’s 60 million family caregivers. Someone suggested creating a Peace Corps-like program to recruit new graduates to serve family caregivers. I immediately volunteered to launch a petition to do just this, and wrote one on the White House website, which encourages civic engagement.

My petition is very short. It seemed to me that in the context of trying to raise interest and garner signatures, I needed to be to the point (http://wh.gov/GURc). It reads:

We petition the Obama Administration to: Create a Caregiver Corps that would include debt forgiveness for college graduates to care for our elders.

More than 60 million Americans are family caregivers. They face challenges: Health suffers. Finances suffer. Families suffer. Aging Boomers will overwhelm our caregiving resources. Let’s create a Caregiver Corps, that would marry college debt forgiveness with programs that place recent graduates with families and aging services providers. Let’s bridge the generational divide that promotes ageism. Let’s do it!

One of my Twitter followers admonished me for my lack of detail. Without it, she said, no one would would take me seriously.  The idea is in its early stages, and would require thoughtful analysis and number-crunching by experts. But in the meantime, here’s the general idea for it.

Why We Need a Caregiver Corps

 Several demographic trends are creating a future that will leave families and our beloved elders overwhelmed, exhausted, and bankrupted by the challenges of living with old old age–that is, living past 80–with multiple chronic conditions that will, no matter what they do, kill them. In any given year, some 60 million Americans serve as family caregivers to another adult, someone who is either old, disabled, or both. (And millions more care for children and young adults who live with serious disabilities, and face even more challenges in terms of education, employment, and so on.)

These families will run square into a medical system that is not prepared to care for them in the ways the need most.  These individuals might sometimes need rescue and cure—but they will more often need long-term supports and services, and help with things like transportation, hygiene, and food.  And while they’ll have plenty of access to ICUs and new hips and knees—they will be shocked and disheartened by the costs of all the things they will need to pay for on their own: private-duty nurses, for instance, and home care; transportation and food and skilled nursing care. Unless these families spend-down to become Medicaid beneficiaries or have adequate long-term care policies, their costs will be out of pocket. And those costs will be beyond reach for most middle-class Americans.

In the meantime, the social services agencies meant to serve aging Americans continue to be devastated by short-sighted budget cuts. Sequestration alone, one estimate suggests, will eliminate 800,000 Meals on Wheels in the State of Maryland.

And there will be few people to provide the hands-on care that these adults will need. The nation faces a profound shortage of people trained in geriatric care, from geriatricians to nurses to direct care workers. These shortages stem, in part, from the relatively low pay geriatricians earn, and the outright unlivable wage direct care workers receive. By one estimate, by 2030, when all of those Boomers are in their dotage, there will be one geriatrician for every 20,000 older adults.

A Caregiver Corps: Hope—and Help–for Us All

What’s a country to do? Launch a Caregiver Corps, a program modeled on similar valuable, successful, and long-lived efforts, such as the Peace Corps, AmeriCorps, VISTA, and Teach for America. The program could recruit volunteers: high school graduates not trained for the workforce; college graduates facing a tough economy and huge undergraduate debt; and older adults, those healthy enough to want to remain in the workforce and contribute to others’ well-being.

Volunteers could sign up for a year or two. In exchange for their service, they could earn tuition credits to cover the cost of college; they could receive some degree of loan forgiveness, to lessen their burden of debt; they could be paid a stipend that acknowledges the value of their work. They could be assigned to community-based organizations that serve older adults, such as Area Agencies on Aging, non-profit health care institutions, social services agencies, and others.

While volunteers could offer enthusiasm, compassion, and insight, they could also learn the kinds of skills required to care for an older adult and his or her family. They could learn about the public policies that affect that care. They could acquire medical and nursing skills—the kind of skills family caregivers use routinely in their daily routine. They could be exposed to older people, and bridge the generational gap that splits our country on this demographic. In the end, they might even be inspired to pursue a career that features caring for one another.

That, it seems to me, is something Americans have always done best—and will have to do more, as we all reach our own old age. Developing people who have the skills, resources, and motivation to help us in our self-interest. And it is in theirs, too. Millenials face the highest unemployment of any group in the country, and finding ways to become marketable, employable adults is critical to their own security and future.

So, let’s try it. Let’s create a Caregiver Corps. Let’s get the Administration to think about it, and weigh in. It’s time, really, to move forward. We need 150 signatures to push the petition to the public pages of We the People. Please take a moment to add yours:

https://petitions.whitehouse.gov/petition/create-caregiver-corps-would-include-debt-forgiveness-college-graduates-care-our-elders/vZ5WhStx

Janice Lynch Schuster specializes in writing about aging, caregiving, and end of life issues, and is a co-author of an award-winning book on the topic, Handbook for Mortals: Guidance for People Facing Serious Illness (Oxford University Press, 2012).