Socioeconomic Status and Mortality: Contribution of health care access and psychological distress among U.S. adults with diagnosed diabetes

OBJECTIVE: Although several studies have examined the association between socioeconomic status (SES) and mortality in the general population, few have investigated this relationship among people with diabetes. This study sought to determine how risk of mortality associated with measures of SES among adults with diagnosed diabetes is mitigated by association with demographics, comorbidities, diabetes treatment, psychological distress, or health care access and utilization. RESEARCH DESIGN AND METHODS: The study included 6,177 adults aged 25 years or older with diagnosed diabetes who participated in the National Health Interview Surveys (1997–2003) linked to mortality data (follow-up through 2006). SES was measured by education attained, financial wealth (either stocks/dividends or home ownership), and income-to-poverty ratio. RESULTS: In unadjusted analysis, risk of death was significantly greater for people with lower levels of education and income-to-poverty ratio than for those at the highest levels. After adjusting for demographics, comorbidities, diabetes treatment and duration, health care access, and psychological distress variables, the association with greater risk of death remained significant only for people with the lowest level of education (relative hazard 1.52 [95% CI 1.04–2.23]). After multivariate adjustment, the risk of death was significantly greater for people without certain measures of financial wealth (e.g., stocks, home ownership) (1.56 [1.07–2.27]) than for those with them. CONCLUSIONS: The findings suggest that after adjustments for demographics, health care access, and psychological distress, the level of education attained and financial wealth remain strong predictors of mortality risk among adults with diabetes.