Rabovsky Andrew J, Rothberg Michael B, Rose Susannah L, Brateanu Andrei, Kou Lei, Misra-Hebert Anita D
From the Case Western Reserve University School of Medicine, Cleveland, OH (AJR); the Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland (MBR, ADM-H); the Department of Bioethics, Cleveland Clinic, Cleveland (SLR); the Department of Internal Medicine, Cleveland Clinic, Cleveland (AB); the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland (LK, ADM-H); and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland (MBR, SLR, AB, ADM-H).
J Am Board Fam Med. 2017 Jan 2;30(1):35-43. doi: 10.3122/jabfm.2017.01.160177. Epub 2017 Jan 6.
Social workers are positioned to address social determinants of health (SDHs), but their specific roles in outpatient primary care practice have not been well described. We aimed to describe needs of patients with diabetes addressed during social work (SW) consultations and their impact on disease control.
This study was a retrospective review of electronic medical records of 977 patients with diabetes with a SW consultation at 3 primary care internal medicine sites in 2014. Diabetes and cardiovascular (CV) risk factor control were assessed before and after the SW encounter. Patient subgroups with uncontrolled diabetes or CV risk factors were compared with propensity-matched patients without a SW encounter. Of the 977 records, 300 were randomly selected for abstraction of needs addressed at the SW consultation using SDH categories established by Wilkinson and Marmot.
Patient insurance status included 52% Medicare and 32% Medicaid. The SDHs most often addressed were social gradient (67%; obtaining medications or health insurance) and social support (25%). Among our total population, there were no significant improvements in glycosylated hemoglobin (HbA), low-density lipoprotein (LDL) cholesterol, systolic blood pressure, or body mass index at least 3 months after the first SW consultation. For patients with uncontrolled diabetes (HbA >9% or LDL cholesterol >130 mg/dl), HbA improved by 1.5 versus 1.1% for matched controls (P = .03) and LDL improved by 37.7 versus 21.3 mg/dl for matched controls (P = .002).
In this sample with a preponderance of Medicare and Medicaid patients, social workers most often assisted patients with diabetes in obtaining medications or health insurance. For patients with uncontrolled diabetes or cholesterol, a temporal association between SW consultation and improved disease control was noted.
社会工作者能够解决健康的社会决定因素（SDH），但其在门诊初级保健实践中的具体作用尚未得到充分描述。我们旨在描述在社会工作（SW）咨询期间所解决的糖尿病患者的需求及其对疾病控制的影响。
本研究是对2014年在3个初级保健内科站点接受SW咨询的977例糖尿病患者的电子病历进行的回顾性分析。在SW会诊前后评估糖尿病和心血管（CV）危险因素控制情况。将糖尿病或CV危险因素未得到控制的患者亚组与倾向匹配的未接受SW会诊的患者进行比较。在977份记录中，随机选择300份，使用威尔金森和马尔莫特建立的SDH类别提取SW咨询中解决的需求。
患者保险状况包括52%为医疗保险和32%为医疗补助。最常涉及的SDH是社会梯度（67%；获取药物或医疗保险）和社会支持（25%）。在我们的总体人群中，首次SW咨询后至少3个月，糖化血红蛋白（HbA）、低密度脂蛋白（LDL）胆固醇、收缩压或体重指数均无显著改善。对于糖尿病未得到控制（HbA>9%或LDL胆固醇>130mg/dl）的患者，HbA改善了1.5%，而匹配对照组改善了-1.1%（P=0.03），LDL改善了37.7mg/dl，而匹配对照组改善了21.3mg/dl（P=0.002）。
在这个以医疗保险和医疗补助患者为主的样本中，社会工作者最常帮助糖尿病患者获取药物或医疗保险。对于糖尿病或胆固醇未得到控制的患者，注意到SW咨询与疾病控制改善之间存在时间关联。
