Food Aid Reduces Hardship, 'Boosts Diabetes Meds Adherence'

Liam Davenport

November 22, 2018

Older patients with diabetes who take part in food aid programs may be better able to afford their medications and so reduce the likelihood that they will be forced into missing prescriptions or treatment, or reducing their doses, to save on medical costs, suggests US survey data.

Jennifer A. Pooler, MPP, and Mithuna Srinivasan, PhD, from IMPAQ International, Columbia, Maryland, studied the impact on cost-related medication nonadherence of participation in the Supplemental Nutrition Assistance Program (SNAP) among more than 1300 older patients with diabetes.

SNAP, a federal aid program, provides assistance to low-income households to purchase food through an electronic benefit card and is the largest food safety net initiative in the United States.

The researchers found that, after accounting for various sociodemographic and health-related factors, older patients with diabetes who participated in SNAP had the equivalent of about a 30% reduction in cost-related medication nonadherence compared with those with diabetes eligible for SNAP but not receiving it.

The research was published online on November 19 in JAMA Internal Medicine.

"This study is the first, to our knowledge, to investigate the relationship between SNAP and cost-related medication nonadherence among older adults with diabetes aged 65 years or older," say Pooler and Srinivasan.

The findings suggest "that even though SNAP is designed to alleviate hunger by providing financial resources to purchase food, the program may also allow individuals to better afford medications," they note.

"This benefit, in turn, may be associated with an improvement in overall health and reduction in the burden of high costs faced by health systems."

They add, "For low-income older patients with diabetes, in particular, these findings offer a potential strategy for improving health outcomes and reducing hypoglycemia: linking patients with social service programs that can help address financial hardship."

Tradeoffs Between Basic Needs

Older patients with diabetes can incur large costs, with medical expenses associated with treating the disease estimated to be as high as $11,825 per year, of which 18% is the cost of prescription medications.

The researchers argue that, for low-income individuals, this can result in tradeoffs between basic needs such as food and medication.

This can manifest as nonadherence — patients skipping or stopping medications, taking lower doses, or delaying or not filling prescriptions — because of cost.

This, say Pooler and Srinivasan, can be "particularly challenging" for patients with diabetes on low incomes, as "both food and medication must be addressed to effectively manage the disease." One report suggests as many as 30% of older adults with diabetes may be forced into nonadherence to medication (World J Diabetes. 2014;5:945-950).

Recent studies have indicated, however, that social programs aimed at improving the daily circumstances of low-income individuals could have knock-on effects in terms of health and healthcare use.

The researchers therefore set out to determine whether participation in SNAP is associated with reduced cost-related medication nonadherence among older patients with diabetes.

Just Over a Third of Those Eligible for SNAP Are Participating

For the study, researchers included data on adults aged 65 years or older who were prescribed medications in the past year and who reported they had been diagnosed with diabetes or borderline diabetes by a health professional. Data were extracted from the National Health Interview Survey on SNAP-eligible patients (based on net income minus allowable deductions) from 2013 to 2016.

The sample was further restricted to individuals who reported having at least some out-of-pocket medical expenses in the past year because the question of economic tradeoffs and affordability of prescription medication is pertinent to this group.

The researchers identified 1385 patients, of whom 503 (36.3%) had participated in SNAP in the past year and 178 (12.8%) reported having been medication nonadherent over the same period because of costs.

To account for baseline demographic differences, they performed two-stage, regression-adjusted propensity-score matching to create matched groups of SNAP participants and eligible nonparticipants. This yielded a final group of 1302 patients, of whom 33.3% were men, 55.0% were non-Hispanic white, and 44.6% were aged 75 years and older.

Logistic regression analysis revealed that SNAP participants had a significant, albeit "moderate", reduction of 5.3 percentage points in the likelihood of cost-related medication nonadherence versus those who were eligible for SNAP but did not participate in the food aid program (P = .03); this was equivalent to a reduction of 31.5% in nonadherence among participants in SNAP, say the researchers.

SNAP participation also had a significant impact on nonadherence among patients with less than $500 in medical costs in the past year, at a reduction of 6.4 percentage points versus those not taking part in SNAP (P = .02).

The team reports that the results held firm when performing several sensitivity analyses.

"For low-income older patients with diabetes, in particular, these findings offer a potential strategy for improving health outcomes and reducing hypoglycemia: linking patients with social service programs that can help address financial hardship," say Pooler and Srinivasan.

They believe that their work points to a number of further research opportunities, including whether increases in SNAP benefits could lead to better management of chronic diseases, and the interaction between SNAP and other social programs in improving medication nonadherence.

Noting that their research relied on repeated cross-sectional data, they write, "with the availability of panel data, a more rigorous longitudinal study examining management of diabetes care, out-of-pocket healthcare costs, and participation in SNAP can be developed."

The authors have reported no relevant financial relationships.

JAMA Intern Med. Published online November 19, 2018. Abstract

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