Screening and Interventions for Social Risk Factors: Technical Brief to Support the US Preventive Services Task Force

Unpacking patient perspectives on social needs screening: A mixed methods study in western Colorado primary care practices

OBJECTIVE

Explore factors influencing patient comfort with and perceived helpfulness of screening for health-related social needs.

METHODS

In a parallel secondary mixed-methods analysis of data from three primary care clinics, we used logistic regression to examine effects of practice- and patient-level factors on comfort with and perceived helpfulness of social needs screening. We applied narrative analysis to 20 patient interviews to further understand how patients' lived experiences influenced their perceptions of screening.

RESULTS

Among 511 patients, receiving an explanation about screening was associated with increased odds of comfort (OR 2.1, 95% CI [1.1-4.30]) and perceived helpfulness (OR 4.7 [2.8-7.8]). Those experiencing more needs were less likely to report comfort (3 + needs vs. 0: OR 0.2 [0.1-0.5]). Narratives elucidated how a history of stigmatizing experiences increased discomfort disclosing needs and captured how relationship quality with healthcare teams influenced perceptions of screening for patients with extensive needs.

CONCLUSION

Practice-level (screening explanation and therapeutic rapport) and patient-level factors (history and extent of needs) are key influences on comfort with and perceived helpfulness of screening.

PRACTICE IMPLICATIONS

Good communication about screening benefits all patients. Patients with extensive social needs may require additional sensitivity to their past experiences.

Care Fragmentation, Social Determinants of Health, and Postoperative Mortality in Older Veterans

INTRODUCTION

Veterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality.

METHODS

VASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH.

RESULTS

In adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835).

CONCLUSIONS

Postoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.

Food Insecurity Associated with Higher Stress, Depressive Symptoms, and Lower Diet Quality among Women Caregivers in North Carolina

BACKGROUND

Research suggests a bidirectional relationship between food insecurity and stress, but few studies have examined associations of food insecurity with stress and other indicators of cardiometabolic health, including depression, diet quality, and body weight, among lower-income women in the U.S.

METHODS

This cross-sectional study analyzed data from lower-income women caregivers living in North Carolina (n = 100): 42% Black/African American, 25% Hispanic/Latina, and 33% White women. Multivariable linear regression models were used to determine associations of food insecurity status with perceived stress, depressive symptoms, diet quality, and body mass index (BMI). Multivariable logistic regression models were used to determine associations of food insecurity with clinical depression and BMI ≥ 30 kg/m2. Associations were examined with and without adjustment for perceived stress.

RESULTS

Forty-two percent of the sample were experiencing food insecurity. Compared to food secure caregivers, food-insecure caregivers had significantly higher perceived stress (β: +7.51; 95%CI: 4.19, 10.84) and depressive symptoms (β: +3.55; 95%CI: 0.54, 6.56) and lower diet quality (β: -9.10; 95%CI: -15.81, -2.40). Associations with BMI outcomes were not statistically significant.

CONCLUSION

Findings support removing stigma in nutrition assistance programs and clinical interactions, motivate future longitudinal studies, and inform the development of destigmatizing interventions for health promotion or disease prevention.

Benefits of using both the Hunger Vital Sign and brief nutrition security screener in health-related social needs screening

Food security is a commonly screened for health-related social need at hospitals and community settings, and until recently, there were no tools to additionally screen for nutrition security. The purpose of this study was to assess the potential advantage of including a one-item brief nutrition security screener (BNSS) alongside the commonly used two-item Hunger Vital Sign (HVS) food security screener for identifying individuals with diet-related health risks. Cross-sectional survey data were collected from April to June 2021. Generalized linear mixed models were used to assess associations between screening status and dietary and health variables. Recruitment was done across five states (California, Florida, Maryland, North Carolina, and Washington) from community-based organizations. Participants (n = 435) were, on average, 44.7 years old (SD = 14.5), predominantly women (77%), and racially/ethnically diverse. In adjusted analyses, being in the food insecure and nutrition insecure group (but not the food insecure and nutrition secure or food secure and nutrition insecure groups) was associated with significantly increased odds for self-reported "fair" or "poor" general health [OR = 2.914 (95% CI = 1.521-5.581)], reporting at least one chronic condition [2.028 (1.024-4.018)], and "low" fruit and vegetable intake [2.421 (1.258-4.660)], compared with the food secure and nutrition secure group. These findings support using both the HVS and BNSS simultaneously in health-related social needs screening to identify participants at the highest risk for poor dietary and health outcomes and warrant further investigation into applying these screeners to clinical and community settings.

Screening for Health-Related Social Needs and Financial Toxicity Among Patients With Cancer Treated With Radiation Therapy: Findings From a Quality Improvement Project

INTRODUCTION

Financial toxicity is common among patients with cancer, as are co-occurring health-related social risks (HRSRs). There is limited evidence to support best practices in screening for HRSRs and financial toxicity in the cancer context. This analysis sought to understand variations of identified needs based on treatment course using data from a large screening program.

METHODS

This 2022 to 2023 screening quality improvement program included four services (breast, gastrointestinal, gynecologic, thoracic) at an urban comprehensive cancer center. The Comprehensive Score for Financial Toxicity measured financial toxicity. Patients completed an HRSR checklist documenting food, housing, medication, or transportation insecurity and financial borrowing practices. Differences were evaluated by treatment course (radiation therapy [RT] versus other treatment and RT plus chemotherapy versus other treatment).

RESULTS

Screening surveys were sent to 70,983 unique patients; 38,249 completed a screening survey (54% response rate). Of responders, 4% (n = 1,686) underwent RT in the 120 days before their survey, and 3% (n = 1,033) received RT in combination with chemotherapy. Overall, patients receiving RT had lower unadjusted Comprehensive Score for Financial Toxicity scores, indicating worse financial toxicity. The proportion of patients receiving RT reporting unmet transportation (15% versus 12%, P < .001) and food (13% versus 11%, P = .02) needs was significantly higher than for patients not receiving RT. More patients receiving RT borrowed money than did patients not receiving RT (17% versus 15%, P = .02). In multivariable models, RT (alone or in combination) was associated with worse financial toxicity and transportation difficulties.

CONCLUSIONS

Screening for financial toxicity and HRSR is possible at a large cancer center. Patients receiving RT have higher transportation insecurity and worse financial toxicity compared with those receiving other treatments. Tailored intervention throughout the treatment trajectory is essential.

Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study

Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.

Evaluating Intensity, Complexity, and Potential for Causal Inference in Social Needs Interventions: A Review of a Scoping Review

Importance

Interventions that address needs such as low income, housing instability, and safety are increasingly appearing in the health care sector as part of multifaceted efforts to improve health and health equity, but evidence relevant to scaling these social needs interventions is limited.

Objective

To summarize the intensity and complexity of social needs interventions included in randomized clinical trials (RCTs) and assess whether these RCTs were designed to measure the causal effects of intervention components on behavioral, health, or health care utilization outcomes.

Evidence Review

This review of a scoping review was based on a Patient-Centered Outcomes Research Institute-funded evidence map of English-language US-based RCTs of social needs interventions published between January 1, 1995, and April 6, 2023. Studies were assessed for features related to intensity (defined using modal values as providing as-needed interaction, 8 participant contacts or more, contacts occurring every 2 weeks or more often, encounters of 30 minutes or longer, contacts over 6 months or longer, or home visits), complexity (defined as addressing multiple social needs, having dedicated staff, involving multiple intervention components or practitioners, aiming to change multiple participant behaviors [knowledge, action, or practice], requiring or providing resources or active assistance with resources, and permitting tailoring), and the ability to assess causal inferences of components (assessing interventions, comparators, and context).

Findings

This review of a scoping review of social needs interventions identified 77 RCTs in 93 publications with a total of 135 690 participants. Most articles (68 RCTs [88%]) reported 1 or more features of high intensity. All studies reported 1 or more features indicative of high complexity. Because most studies compared usual care with multicomponent interventions that were moderately or highly dependent on context and individual factors, their designs permitted causal inferences about overall effectiveness but not about individual components.

Conclusions and Relevance

Social needs interventions are complex, intense, and include multiple components. Our findings suggest that RCTs of these interventions address overall intervention effectiveness but are rarely designed to distinguish the causal effects of specific components despite being resource intensive. Future studies with hybrid effectiveness-implementation and sequential designs, and more standardized reporting of intervention intensity and complexity could help stakeholders assess the return on investment of these interventions.

Revising the Logic Model Behind Health Care's Social Care Investments

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

Development and content validation of a questionnaire to assess the social determinants of mental health in clinical practice

Introduction

There is growing consensus that consideration of the Social Determinants of Mental Health should be at the centre of mental health care provision. To facilitate this, a validated means to assess mental health service users' social contextual information is arguably needed. We therefore developed a questionnaire to assess the Social Determinants of Mental Health in clinical practice.

Methods

Our guideline-informed development consisted of three steps; i) construct and purpose definition, ii) initial item generation based on the literature, similar questionnaires, and a selection of the ICD-10, iii) evaluation, revision, and content validation of the questionnaire. Initially we developed 249 items that were reduced, revised, and validated in several stages to 73 items. Content validation of the questionnaire was achieved through surveys and focus groups including mental health care service users and professionals.

Results

The surveys and focus groups indicated the need for a standardised assessment of adverse social factors and highlighted that the benefits of such an assessment would be a more holistic approach to identifying and addressing fundamental factors involved in the development of mental health difficulties. Importantly, this study also revealed how any assessment of the Social Determinants of Mental Health must prioritise the assessed person having a central role in the process and control over their own data. The focus groups identified contradicting recommendations regarding the most suitable context to administer the questionnaire.

Discussion

The resulting questionnaire can be considered to be theoretically robust and partially validated. Future research is discussed.

Bundling Colorectal Cancer Screening Outreach with Screening for Social Risk in Federally Qualified Health Centers: A Stepped-Wedge Implementation-Effectiveness Study

BACKGROUND

Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies.

OBJECTIVE

To measure effects of bundling fecal immunochemical testing (FIT) and SDOH screening in federally qualified health centers (FQHCs).

DESIGN

Clustered stepped-wedge trial.

PARTICIPANTS

Four Massachusetts FQHCs randomized to implement bundled FIT-SDOH over 8-week "steps."

INTERVENTION

Outreach to 50-75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting.

MAIN MEASURES

Implementation process descriptions, data from facilitation meetings, and CRC and SDOH screening rates. Rates were compared between implementation and control FQHCs in each "step" by fitting generalized linear mixed-effects models with random intercepts for FQHCs, patients, and "step" by FQHC.

KEY RESULTS

FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation "steps" compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across "steps."

CONCLUSIONS

As healthcare systems are required to conduct more screenings, it is notable that outreach for a long-standing cancer screening requirement increased screening, even when bundled with a newer screening requirement. This outreach was feasible in a real-world safety-net clinical population and may conserve resources, especially compared to more complex or intensive outreach strategies.

CLINICAL TRIALS REGISTRATION

NCT04585919.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

In-person versus electronic screening for social risks among carers of pediatric inpatients: A mixed methods randomized trial

We aimed to compare disclosure of social risks according to self-report on an iPad versus face-to-face questions from a health professional and to explore carers' experiences of screening. This two-arm, parallel group, randomized trial was conducted from January 19, 2021, to December 17, 2021, in a public hospital pediatric ward serving a disadvantaged area of an Australian capital city. Carers of children aged ≤ 5 years admitted to the Children's Ward were eligible. The primary outcome was disclosure of social risks. The screener included nine items on food security, household utilities, transport, employment, personal and neighborhood safety, social support, housing and homelessness. Disclosure of social risks was similar between the self-completion (n = 193) and assisted-completion (n = 193) groups for all 9 items, ranging 4.1% higher for worrying about money for food (95% CI - 11.4, 3.1%) among the assisted-completion group, to 5.7% (-1.6, 13.0%) higher for unemployment among the self-completion group. In qualitative interviews, participants were positive about screening for social risks in the hospital ward setting and the majority indicated a preference for self-completion.  Conclusion: Differences in the disclosure of social risks according to self- versus assisted-completion were small, suggesting that either method could be used. Most carers expressed a preference for self- completion, which is therefore recommended as the ideal mode for such data collection for Australian pediatric inpatient settings.  Trial registration: Australia New Zealand Clinical Trial Registry ( www.anzctry.org.au ; #ACTRN12620001326987; date of registration 8 December 2020). What is Known: • Most evidence on screening of social risks in pediatric inpatient settings is from the USA. • Little is known about disclosure of social risks in countries with universal health care and social welfare. What is New: • Disclosure of social risks was similar for electronic compared with face-to-face screening. • Carers preferred electronic completion over face-to-face completion.

Digital Redlining-The Invisible Structural Determinant of Health

This Viewpoint describes digital redlining as racialized inequities in access to technology infrastructure, including access to health care, education, employment, and social services.

Screening for social determinants of health among populations at risk for MASLD: a scoping review

Background

Social determinants of health (SDoH) have been associated with disparate outcomes among those with metabolic dysfunction-associated steatotic liver disease (MASLD) and its risk factors. To address SDoH among this population, real-time SDoH screening in clinical settings is required, yet optimal screening methods are unclear. We performed a scoping review to describe the current literature on SDoH screening conducted in the clinical setting among individuals with MASLD and MASLD risk factors.

Methods

Through a systematic literature search of MEDLINE, Embase, and CINAHL Complete databases through 7/2023, we identified studies with clinic-based SDoH screening among individuals with or at risk for MASLD that reported pertinent clinical outcomes including change in MASLD risk factors like diabetes and hypertension.

Results

Ten studies (8 manuscripts, 2 abstracts) met inclusion criteria involving 148,151 patients: 89,408 with diabetes and 25,539 with hypertension. Screening was primarily completed in primary care clinics, and a variety of screening tools were used. The most commonly collected SDoH were financial stability, healthcare access, food insecurity and transportation. Associations between clinical outcomes and SDoH varied; overall, higher SDoH burden was associated with poorer outcomes including elevated blood pressure and hemoglobin A1c.

Conclusion

Despite numerous epidemiologic studies showing associations between clinical outcomes and SDoH, and guidelines recommending SDoH screening, few studies describe in-clinic SDoH screening among individuals with MASLD risk factors and none among patients with MASLD. Future research should prioritize real-time, comprehensive assessments of SDoH, particularly among patients at risk for and with MASLD, to mitigate disease progression and reduce MASLD health disparities.

Interventions addressing health-related social needs among patients with cancer

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

Contextual Factors Relevant to Implementing Social Risk Factor Screening and Referrals in Cancer Survivorship: A Qualitative Study

Introduction

Social risk factors such as food insecurity and lack of transportation can negatively affect health outcomes, yet implementation of screening and referral for social risk factors is limited in medical settings, particularly in cancer survivorship.

Methods

We conducted 18 qualitative, semistructured interviews among oncology teams in 3 health systems in Washington, DC, during February and March 2022. We applied the Exploration, Preparation, Implementation, Sustainment Framework to develop a deductive codebook, performed thematic analysis on the interview transcripts, and summarized our results descriptively.

Results

Health systems varied in clinical and support staff roles and capacity. None of the participating clinics had an electronic health record (EHR)-based process for identifying patients who completed their cancer treatment ("survivors") or a standardized cancer survivorship program. Their capacities also differed for documenting social risk factors and referrals in the EHR. Interviewees expressed awareness of the prevalence and effect of social risk factors on cancer survivors, but none employed a systematic process for identifying and addressing social risk factors. Recommendations for increasing screening for social risk factors included designating a person to fulfill this role, improving data tracking tools in the EHR, and creating systems to maintain up-to-date information and contacts for community-based organizations.

Conclusion

The complexity of cancer care workflows and lack of reimbursement results in a limited ability for clinic staff members to screen and make referrals for social risk factors. Creating clinical workflows that are flexible and tailored to staffing realities may contribute to successful implementation of a screening and referral program. Improving ongoing communication with community-based organizations to address needs was deemed important by interviewees.

Understanding Health-Related Social Risks

Because of the established contribution of social factors to health outcomes, approaches that address upstream determinants of health have increasingly been recognized as cost-effective means to improve population health. Understanding and usage of precise terminology is important to facilitate collaboration across disciplines. Social determinants of health affect everyone, not just the socially and economically disadvantaged, whereas health-related social risks (HRSR) are specific adverse conditions at the individual or family level that are associated with poor health and related to the immediate challenges individuals face. Health-related social needs account for patient preference in addressing identified social risks. The use of validated screening tools is important to capture risk factors in a standardized fashion to support research and quality improvement. There is a paucity of studies that address HRSR in the context of radiology. This review provides an understanding of HRSR and outlines various ways in which radiologists can work to mitigate them.

The relationship between community social risk factors and regional hospital-reported cash, negotiated, and chargemaster prices for 14 common services

BACKGROUND

Social risk factors are key drivers of the geographic variation in spending in the United States but little is known how community-level social risk factors are associated with hospital prices. Our objective was to describe the relationship between regional hospital-reported prices and social risk factors by price type (chargemaster, cash, commercial, Medicare, and Medicaid).

METHODS

This cross-sectional analysis used newly available hospital-reported prices from acute general hospitals in 2022. The prices were for 14 common services. Prices were winsorized at 98%, wage index-adjusted, standardized by service, and aggregated to hospital service areas (HSAs). For social risk, we used 23 measures across 5 domains of social risk (socioeconomic position; race, ethnicity, and culture; gender; social relationships; and residential and community context). Spearman's correlation was used to estimate associations between median prices and social risk by price type.

RESULTS

Prices were reported from 2,386 acute general hospitals in 45% (1,502 of 3,436) HSAs. Correlations between regional prices and other social risk factors varied by price type (range: -0.19 to 0.31). Chargemaster and cash prices were significantly correlated with the most community characteristics (10 of 23, 43%) followed by commercial prices (8, 35%). Medicare and Medicaid prices were only significantly correlated with 1 measure (all p < 0.01). All price types were significantly correlated with the percentage of uninsured (all p < 0.01). Chargemaster, cash, and commercial prices were positively correlated with percentage of Hispanic residents, residents with limited English proficiency, and non-citizens (all p < 0.05).

CONCLUSIONS

While regional correlations between prices and social risk factors were weak across all prices, chargemaster, cash, and commercial prices were more like closely aligned with community-level social risk factors than the two public payers (Medicare and Medicaid). Chargemaster, cash, and commercial hospital prices appeared to be higher in socially disadvantaged communities. Further research is needed to clarify the relationship between prices and community social risk factors.

Differences in up-to-date colorectal and cervical cancer screening rates by ethnicity and preferred language: An analysis across patient-, clinic-, and area-level data sources

Research objective

There is interest in using clinic- and area-level data to inform cancer control, but it is unclear what value these sources may add in combination with patient-level data sources. This study aimed to investigate associations of up-to-date colorectal and cervical cancer screenings at community health centers (CHCs) with ethnicity and language variables at patient-, clinic-, and area-levels, while exploring whether patient-level associations differed based on clinic-level patient language and ethnicity distributions.

Study design

This was a cross-sectional study using data from multiple sources, including electronic health records, clinic patient panel data, and area-level demographic data. The study sample included English-preferring Hispanic, Spanish-preferring Hispanic, English-preferring non-Hispanic, and non-English-preferring non-Hispanic patients eligible for either colorectal cancer (N = 98,985) or cervical cancer (N = 129,611) screenings in 2019 from 130 CHCs in the OCHIN network in CA, OR, and WA.

Population studied

The study population consisted of adults aged 45+ eligible for colorectal cancer screening and adults with a cervix aged 25-65 eligible for cervical cancer screening.

Principal findings

Spanish-preferring Hispanic patients were significantly more likely to be up-to-date with colorectal and cervical cancer screenings than other groups. Patients seen at clinics with higher concentrations of Spanish-preferring Hispanics were significantly more likely to be up-to-date, as were individuals residing in areas with higher percentages of Spanish-speaking residents. Differential associations between patient ethnicity and language and up-to-date colorectal cancer screenings were greater among patients seen at clinics with higher concentrations of Spanish-preferring Hispanics.

Conclusions

The findings highlight that Spanish-speaking Hispanics seen in CHCs have higher rates of up-to-date cervical and colorectal cancer screenings than other groups and that this relationship is stronger at clinics with higher percentages of Spanish-preferring Hispanic patients. Our findings suggest area-level variables are not good substitutions for patient-level data, but variables at the clinic patient panel-level are more informative.

Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy

OBJECTIVE

To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model.

DATA SOURCES AND STUDY SETTING

Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention.

STUDY DESIGN

This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015.

DATA COLLECTION/EXTRACTION METHODS

Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded.

PRINCIPAL FINDINGS

After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function.

CONCLUSIONS

We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.

Evaluation of the Predictive Value of Routinely Collected Health-Related Social Needs Measures

The objective was to assess the value of routinely collected patient-reported health-related social needs (HRSNs) measures for predicting utilization and health outcomes. The authors identified Mayo Clinic patients with cancer, diabetes, or heart failure. The HRSN measures were collected as part of patient-reported screenings from June to December 2019 and outcomes (hospitalization, 30-day readmission, and death) were ascertained in 2020. For each outcome and disease combination, 4 models were used: gradient boosting machine (GBM), random forest (RF), generalized linear model (GLM), and elastic net (EN). Other predictors included clinical factors, demographics, and area-based HRSN measures-area deprivation index (ADI) and rurality. Predictive performance for models was evaluated with and without the routinely collected HRSN measures as change in area under the curve (AUC). Variable importance was also assessed. The differences in AUC were mixed. Significant improvements existed in 3 models of death for cancer (GBM: 0.0421, RF: 0.0496, EN: 0.0428), 3 models of hospitalization (GBM: 0.0372, RF: 0.0640, EN: 0.0441), and 1 of death (RF: 0.0754) for diabetes, and 1 model of readmissions (GBM: 0.1817), and 3 models of death (GBM: 0.0333, RF: 0.0519, GLM: 0.0489) for heart failure. Age, ADI, and the Charlson comorbidity index were the top 3 in variable importance and were consistently more important than routinely collected HRSN measures. The addition of routinely collected HRSN measures resulted in mixed improvement in the predictive performance of the models. These findings suggest that existing factors and the ADI are more important for prediction in these contexts. More work is needed to identify predictors that consistently improve model performance.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic

OBJECTIVE

To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020.

DATA SOURCE

2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375).

STUDY DESIGN

We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers.

DATA COLLECTION

None.

PRINCIPAL FINDINGS

In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%).

CONCLUSIONS

Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

Inflammation and poverty as individual and combined predictors of 15-year mortality risk in middle aged and older adults in the US

Background

Chronic systemic inflammation and poverty are both linked to an increased mortality risk. The goal of this study was to determine if there is a synergistic effect of the presence of inflammation and poverty on the 15-year risk of all-cause, heart disease and cancer mortality among US adults.

Methods

We analyzed the nationally representative National Health and Nutrition Examination Survey (NHANES) 1999 to 2002 with linked records to the National Death Index through the date December 31, 2019. Among adults aged 40 and older, 15-year mortality risk associated with inflammation, C-reactive protein (CRP), and poverty was assessed in Cox regressions. All-cause, heart disease and cancer mortality were the outcomes.

Results

Individuals with elevated CRP at 1.0 mg/dL and poverty were at greater risk of 15-year adjusted, all-cause mortality (HR = 2.45; 95% CI 1.64, 3.67) than individuals with low CRP and were above poverty. For individuals with just one at risk characteristic, low inflammation/poverty (HR = 1.58; 95% CI 1.30, 1.93), inflammation/above poverty (HR = 1.59; 95% CI 1.31, 1.93) the mortality risk was essentially the same and substantially lower than the risk for adults with both. Individuals with both elevated inflammation and living in poverty experience a 15-year heart disease mortality risk elevated by 127% and 15-year cancer mortality elevated by 196%.

Discussion

This study extends the past research showing an increased mortality risk for poverty and systemic inflammation to indicate that there is a potential synergistic effect for increased mortality risk when an adult has both increased inflammation and is living in poverty.

Screening for Unstable Housing in a Healthcare Setting

Objectives: To describe existing tools for screening patients for unstable housing in a healthcare setting. Methods: A literature search was completed to retrieve articles published in the last 10 years on screening patients for unstable housing in a healthcare setting. Results: The current literature on screening patients for homelessness in healthcare settings describes a variety of tools administered by a range of healthcare providers, but all are based in the United States. Conclusion: The studies revealed the potential for effective screening in healthcare settings and positive engagement of patients and providers with screening. Key areas for future research include innovative methods of screening and evaluation of reliability and validity for a broader range of tools.

Integrating social care into gynecologic oncology: Identifying and addressing patient's social needs

OBJECTIVE

We aimed to identify social needs of gynecologic oncology patients using a self-administered social needs assessment tool (SNAT), compare the SNAT to a formal social work assessment performed by cancer care navigators (CCN), and provide SNAT-informed community resources.

METHODS

We analyzed prospectively collected data from a performance improvement initiative in a safety-net gynecologic oncology clinic between October 2021 and July 2022. We screened for eight social needs domains, health literacy, desire for social work, and presence of urgent needs. Clinicodemographic data were abstracted from the electronic medical record. Univariate descriptive statistics were used. Inter-rater reliability for social needs domains was assessed using percent agreement.

RESULTS

1010 unique patients were seen over this study period. 488 (48%) patients completed the SNAT, of which 265 (54%) screened positive for ≥1 social need. 83 (31%) patients were actively receiving cancer treatment, 140 (53%) were in post-treatment surveillance, and 42 (16%) had benign gynecologic diagnoses. Transportation (19% vs 25%), housing insecurity (18% vs 19%), and desire to speak with a social worker (16% vs 27%) were the 3 most common needs in both the entire cohort and among patients actively receiving cancer treatment. 78% patients in active treatment were seen by a CCN and received SNAT informed community resources. The percent agreement between the SNAT and formal CCN assessment ranged from 72%-94%.

CONCLUSIONS

The self-administered SNAT identified many unmet social needs among gynecologic oncology patients, corresponded well with the formal social work CCN assessment, and informed the provision of community resources.

A Systematic Review of Electronic Community Resource Referral Systems

INTRODUCTION

Community Resource Referral Systems delivered electronically through healthcare information technology systems (e.g., electronic medical records) have become more common in efforts to address patients' unmet health-related social needs. Community Resource Referral System connects patients with social supports such as food assistance, utility support, transportation, and housing. This systematic review identifies barriers and facilitators that influence the Community Resource Referral System's implementation in the U.S. by identifying and synthesizing peer-reviewed literature over a 15-year period.

METHODS

This systematic review was conducted following PRISMA guidelines. A search was conducted on five scientific databases to capture the literature published between January 2005 and December 2020. Data analysis was conducted from August 2021 to July 2022.

RESULTS

This review includes 41 articles of the 2,473 initial search results. Included literature revealed that Community Resource Referral Systems functioned to address a variety of health-related social needs and were delivered in different ways. Integrating the Community Resource Referral Systems into clinic workflows, maintenance of community-based organization inventories, and strong partnerships between clinics and community-based organizations facilitated implementation. The sensitivity of health-related social needs, technical challenges, and associated costs presented as barriers. Overall, electronic medical records-integration and automation of the referral process was reported as advantageous for the stakeholders.

DISCUSSION

This review provides information and guidance for healthcare administrators, clinicians, and researchers designing or implementing electronic Community Resource Referral Systems in the U.S. Future studies would benefit from stronger implementation science methodological approaches. Sustainable funding mechanisms for community-based organizations, clear stipulations regarding how healthcare funds can be spent on health-related social needs, and innovative governance structures that facilitate collaboration between clinics and community-based organizations are needed to promote the growth and sustainability of Community Resource Referral Systems in the U.S.

Area-level social determinants of health and individual-level social risks: Assessing predictive ability and biases in social risk screening

Introduction

Area-level social determinants of health (SDoH) and individual-level social risks are different, yet area-level measures are frequently used as proxies for individual-level social risks. This study assessed whether demographic factors were associated with patients being screened for individual-level social risks, the percentage who screened positive for social risks, and the association between SDoH and patient-reported social risks in a nationwide network of community-based health centers.

Methods

Electronic health record data from 1,330,201 patients with health center visits in 2021 were analyzed using multilevel logistic regression. Associations between patient characteristics, screening receipt, and screening positive for social risks (e.g., food insecurity, housing instability, transportation insecurity) were assessed. The predictive ability of three commonly used SDoH measures (Area Deprivation Index, Social Deprivation Index, Material Community Deprivation Index) in identifying individual-level social risks was also evaluated.

Results

Of 244,155 (18%) patients screened for social risks, 61,414 (25.2%) screened positive. Sex, race/ethnicity, language preference, and payer were associated with both social risk screening and positivity. Significant health system-level variation in both screening and positivity was observed, with an intraclass correlation coefficient of 0.55 for social risk screening and 0.38 for positivity. The three area-level SDoH measures had low accuracy, sensitivity, and area under the curve when used to predict individual social needs.

Conclusion

Area-level SDoH measures may provide valuable information about the communities where patients live. However, policymakers, healthcare administrators, and researchers should exercise caution when using area-level adverse SDoH measures to identify individual-level social risks.

Evaluation of Income and Food Insecurity as Risk Factors for Failure to Thrive: An Analysis of National Survey Data

Limited data exist regarding the relationship between socioeconomic risk factors and failure to thrive (FTT). Using data from the National Health and Nutrition Examination Survey (NHANES) from years 1999 to 2014, we sought to determine whether there was a higher prevalence of underweight (<5th percentile weight-for-age [WFA], weight-for-length [WFL], or body mass index-for-age [BFA]), and, therefore, likely a higher risk of FTT, in US children <3 years with low household income or food insecurity compared with children without these factors. Among 7356 evaluated children, there were no significant differences in the prevalence of underweight by adjusted household income quintile, food security, household Women, Infants, and Children (WIC) status, or federal poverty income ratio. These findings do not support a link between low income or food security and underweight in children and, therefore, do not provide support for an association between low income or food security and FTT.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study

OBJECTIVE

Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation.

METHODS

We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data.

RESULTS

Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data.

CONCLUSIONS

This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

Screening for Social Determinants of Health During Prenatal Care: Why, What, and How

As more data from maternal mortality reviews are available, it has become clear that social determinants of health have major impacts on the morbidity and mortality of mothers and infants. The ability to verify and address these requires an effective screening process during prenatal care. The challenges include selection of an appropriate tool for use in pregnancy; incorporating the tool into the clinical flow to ensure screening of all pregnant patients; and developing an approach to address the issues, be it providing emotional support, management within the clinic, or referring to outside resources.

Screening for Health-Related Social Needs and Collaboration With External Partners Among US Hospitals

Importance

In recent years, hospitals and health systems have reported increasing rates of screening for patients' individual and community social needs, but few studies have explored the national landscape of screening and interventions directed at addressing health-related social needs (HRSNs) and social determinants of health (SDOH).

Objective

To evaluate the associations of hospital characteristics and area-level socioeconomic indicators to quantify the presence and intensity of hospitals' screening practices, interventions, and collaborative external partnerships that seek to measure and ameliorate patients' HRSNs and SDOH.

Design, Setting, and Participants

This cross-sectional study used national data from the American Hospital Association Annual Survey Database for fiscal year 2020. General-service, acute-care, nonfederal hospitals were included in the study's final sample, representing nationally diverse hospital settings. Data were analyzed from July 2022 to February 2023.

Exposures

Organizational characteristics and area-level socioeconomic indicators.

Main Outcomes and Measures

The outcomes of interest were hospital-reported patient screening of and strategies to address 8 HRSNs and 14 external partnership types to address SDOH. Composite scores for screening practices and external partnership types were calculated, and ordinary least-square regression analyses tested associations of organizational characteristics with outcome measures.

Results

Of 2858 US hospital respondents (response rate, 67.0%), most hospitals (79.2%; 95% CI, 77.7%-80.7%) reported screening patients for at least 1 HRSN, with food insecurity or hunger needs (66.1%; 95% CI, 64.3%-67.8%) and interpersonal violence (66.4%; 95% CI, 64.7%-68.1%) being the most commonly screened social needs. Most hospitals (79.4%; 95% CI, 66.3%-69.7%) reported having strategies and programs to address patients' HRSNs; notably, most hospitals (52.8%; 95% CI, 51.0%-54.5%) had interventions for transportation barriers. Hospitals reported a mean of 4.03 (95% CI, 3.85-4.20) external partnership types to address SDOH and 5.69 (5.50-5.88) partnership types to address HRSNs, with local or state public health departments and health care practitioners outside of the health system being the most common. Hospitals with accountable care contracts (ACCs) and bundled payment programs (BPPs) reported higher screening practices (ACC: β = 1.03; SE = 0.13; BPP: β = 0.72; SE = 0.14), interventions (ACC: β = 1.45; SE = 0.12; BPP: β = 0.61; SE = 0.13), and external partnership types to address HRSNs (ACC: β = 2.07; SE = 0.23; BPP: β = 1.47; SE = 0.24) and SDOH (ACC: β = 2.64; SE = 0.20; BPP: β = 1.57; SE = 0.21). Compared with nonteaching, government-owned, and for-profit hospitals, teaching and nonprofit hospitals were also more likely to report more HRSN-directed activities. Patterns based on geographic and area-level socioeconomic indicators did not emerge.

Conclusions and Relevance

This cross-sectional study found that most US hospitals were screening patients for multiple HRSNs. Active participation in value-based care, teaching hospital status, and nonprofit status were the characteristics most consistently associated with greater overall screening activities and number of related partnership types. These results support previously posited associations about which types of hospitals were leading screening uptake and reinforce understanding of the role of hospital incentives in supporting health equity efforts.

Social Risk Screening and Response Equity: Assessment by Race, Ethnicity, and Language in Community Health Centers

INTRODUCTION

Little has previously been reported about the implementation of social risk screening across racial/ethnic/language groups. To address this knowledge gap, the associations between race/ethnicity/language, social risk screening, and patient-reported social risks were examined among adult patients at community health centers.

METHODS

Patient- and encounter-level data from 2016 to 2020 from 651 community health centers in 21 U.S. states were used; data were extracted from a shared Epic electronic health record and analyzed between December 2020 and February 2022. In adjusted logistic regression analyses stratified by language, robust sandwich variance SE estimators were applied with clustering on patient's primary care facility.

RESULTS

Social risk screening occurred at 30% of health centers; 11% of eligible adult patients were screened. Screening and reported needs varied significantly by race/ethnicity/language. Black Hispanic and Black non-Hispanic patients were approximately twice as likely to be screened, and Hispanic White patients were 28% less likely to be screened than non-Hispanic White patients. Hispanic Black patients were 87% less likely to report social risks than non-Hispanic White patients. Among patients who preferred a language other than English or Spanish, Black Hispanic patients were 90% less likely to report social needs than non-Hispanic White patients.

CONCLUSIONS

Social risk screening documentation and patient reports of social risks differed by race/ethnicity/language in community health centers. Although social care initiatives are intended to promote health equity, inequitable screening practices could inadvertently undermine this goal. Future implementation research should explore strategies for equitable screening and related interventions.

Non-response Bias in Social Risk Factor Screening Among Adult Emergency Department Patients

Healthcare organizations increasingly use screening questionnaires to assess patients' social factors, but non-response may contribute to selection bias. This study assessed differences between respondents and those refusing participation in a social factor screening. We used a cross-sectional approach with logistic regression models to measure the association between subject characteristics and social factor screening questionnaire participation. The study subjects were patients from a mid-western state safety-net hospital's emergency department. Subjects' inclusion criteria were: (1) ≥ 18 years old, (2) spoke English or Spanish, and (3) able to complete a self-administered questionnaire. We classified subjects that consented and answered the screening questionnaire in full as respondents. All others were non-respondents. Using natural language processing, we linked all subjects' participation status to demographic characteristics, clinical data, an area-level deprivation measure, and social risk factors extracted from clinical notes. We found that nearly 6 out of every 10 subjects approached (59.9%), consented, and completed the questionnaire. Subjects with prior documentation of financial insecurity were 22% less likely to respond to the screening questionnaire (marginal effect = -22.40; 95% confidence interval (CI) = -41.16, -3.63; p = 0.019). No other factors were significantly associated with response. This study uniquely contributes to the growing social determinants of health literature by confirming that selection bias may exist within social factor screening practices and research studies.

Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study

Introduction

Interventions to address social needs in clinical settings can improve child and family health outcomes. Electronic health record (EHR) tools are available to support these interventions but are infrequently used. This mixed-methods study sought to identify approaches for implementing social needs interventions using an existing EHR module in pediatric primary care.

Methods

We conducted focus groups and interviews with providers and staff (n = 30) and workflow assessments (n = 48) at four pediatric clinics. Providers and staff completed measures assessing the acceptability, appropriateness, and feasibility of social needs interventions. The Consolidated Framework for Implementation Research guided the study. A hybrid deductive-inductive approach was used to analyze qualitative data.

Results

Median scores (range 1-5) for acceptability (4.9) and appropriateness (5.0) were higher than feasibility (3.9). Perceived barriers to implementation related to duplicative processes, parent disclosure, and staffing limitations. Facilitators included the relative advantage of the EHR module compared to existing documentation practices, importance of addressing social needs, and compatibility with clinic culture and workflow. Self-administered screening was seen as inappropriate for sensitive topics. Strategies identified included providing resource lists, integrating social needs assessments with existing screening questionnaires, and reducing duplicative documentation.

Conclusions

This study offers insight into the implementation of EHR-based social needs interventions and identifies strategies to promote intervention uptake. Findings highlight the need to design interventions that are feasible to implement in real-world settings. Future work should focus on integrating multiple stakeholder perspectives to inform the development of EHR tools and clinical workflows to support social needs interventions.

"Addressing the bigger picture": A qualitative study of internal medicine patients' perspectives on social needs data collection and use

BACKGROUND

There is increasing interest in collecting sociodemographic and social needs data in hospital settings to inform patient care and health equity. However, few studies have examined inpatients' views on this data collection and what should be done to address social needs. This study describes internal medicine inpatients' perspectives on the collection and use of sociodemographic and social needs information.

METHODS

A qualitative interpretive description methodology was used. Semi-structured interviews were conducted with 18 patients admitted to a large academic hospital in Toronto, Canada. Participants were recruited using maximum variation sampling for diverse genders, races, and those with and without social needs. Interviews were coded using a predominantly inductive approach and a thematic analysis was conducted.

RESULTS

Patients expressed that sociodemographic and social needs data collection is important to offer actionable solutions to address their needs. Patients described a gap between their ideal care which would attend to social needs, versus the reality that hospital-based teams are faced with competing priorities and pressures that make it unfeasible to provide such care. They also believed that this data collection could facilitate more holistic, integrated care. Patients conveyed a need to have a trusting and transparent relationship with their provider to alleviate concerns surrounding bias, discrimination, and confidentiality. Lastly, they indicated that sociodemographic and social needs data could be useful to inform care, support research to inspire social change, and assist them with navigating community resources or creating in-hospital programs to address unmet social needs.

CONCLUSIONS

While the collection of sociodemographic and social needs information in hospital settings is generally acceptable, there were varied views on whether hospital staff should intervene, as their priority is medical care. The results can inform the implementation of social data collection and interventions in hospital settings.

Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review

Introduction

As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans.

Methods

The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire.

Results

The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder.

Discussion

Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.

Social Determinants of Health-Related Z Codes and Health Care Among Patients With Hypertension

Introduction

Tracking social needs can provide information on barriers to controlling hypertension and the need for wraparound services. No recent studies have examined ICD-10-CM social determinants of health-related Z codes (Z55-Z65) to indicate social needs with a focus on patients with hypertension.

Methods

Three cohorts were identified with a diagnosis of hypertension during 2016-2017 and continuously enrolled in fee-for-service insurance through June 2021: (1) commercial, age 18-64 years (n=1,024,012); (2) private insurance to supplement Medicare (Medicare Supplement), age ≥65 years (n=296,340); and (3) Medicaid, age ≥18 years (n=146,484). Both the proportion of patients and healthcare encounters or visits with social determinants of health-related Z code were summarized annually. Patient and visit characteristics were summarized for 2019.

Results

In 2020, the highest annual documentation of social determinants of health-related Z codes was among Medicaid beneficiaries (3.02%, 0.46% commercial, 0.42% Medicare Supplement); documentation was higher among inpatient than among outpatient visits for all insurance types. Z63 (related to primary support group) was more common among commercial and Medicare Supplement beneficiaries, and Z59 (housing and economic circumstances) was more common among Medicaid beneficiaries. The 2019 total unadjusted medical expenditures were 1.85, 1.78, and 1.61 times higher for those with social determinants of health-related Z code than for those without commercial, Medicare Supplement, and Medicaid, respectively. Patients with social determinants of health-related Z code also had higher proportions of diagnosed chronic conditions. Among Medicaid beneficiaries, differences in the presence of social determinants of health-related Z code by race or ethnicity were observed.

Conclusions

Although currently underreported, social determinants of health-related Z codes provide an opportunity to integrate social and medical data and may help decision makers understand the need for additional services among individuals with hypertension.

Go-along interview assessment of community health priorities for neighborhood renewal

Healthcare systems are increasingly investing in approaches to address social determinants of health and health disparities. Such initiatives dovetail with certain approaches to neighborhood development, such as the EcoDistrict standard for community development, that prioritize both ecologically and socially sustainable neighborhoods. However, healthcare system and community development initiatives can be untethered from the preferences and lived realities of residents in the very neighborhoods upon which they focus. Utilizing the go-along approach to collecting qualitative data in situ, we interviewed 19 adults to delineate residents' community health perspectives and priorities. Findings reveal health priorities distinct from clinical outcomes, with residents emphasizing social connectedness, competing intra- and interneighborhood perceptions that potentially thwart social connectedness, and a neighborhood emplacement of agency, dignity, and self-worth. Priorities of healthcare systems and community members alike must be accounted for to optimize efforts that promote health and social well-being by being valid and meaningful to the community of focus.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Stakeholder perspectives on social screening in US healthcare settings

BACKGROUND

Evidence on the health impacts of social conditions has led US healthcare systems to consider identifying and addressing social adversity-e.g. food, housing, and transportation insecurity-in care delivery settings. Social screening is one strategy being used to gather patient information about social circumstances at the point of care. While several recent studies describe the rapid proliferation of social screening activities, little work has explored either why or how to implement social screening in clinical settings. Our study objectives were to assess diverse healthcare stakeholder perspectives on both the rationale for social screening and evidence needed to inform practice and policy-relevant implementation decisions.

METHODS

We convened five focus groups with US experts representing different stakeholder groups: patient advocates, community-based organizations, healthcare professionals, payers, and policymakers. In total, 39 experts participated in approximately 90-minute long focus groups conducted between January-March 2021. A inductive thematic analysis approach was used to analyze discussions.

RESULTS

Three themes emerged from focus groups, each reflecting the tension between the national enthusiasm for screening and existing evidence on the effectiveness and implementation of screening in clinical settings: (1) ambiguity about the rationale for social screening; (2) concerns about the relavence of screening tools and approaches, particularly for historically marginalized populations; (3) lack of clarity around the resources needed for implementation and scaling.

CONCLUSION

While participants across groups described potential benefits of social screening, they also highlighted knowledge gaps that interfered with realizing these benefits. Efforts to minimize and ideally resolve these knowledge gaps will advance future social screening practice and policy.

Accuracy of Electronic Health Record Food Insecurity, Housing Instability, and Financial Strain Screening in Adult Primary Care

This study assesses the accuracy of electronic health record–based screening questionnaires about social risk factors using external single-domain questionnaires as a comparator.

Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs

INTRODUCTION

Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH.

METHODS

Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs.

RESULTS

Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million.

CONCLUSIONS

Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.

Academic Medicine's Fourth Mission: Building on Community-Oriented Primary Care to Achieve Community-Engaged Health Care

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care.

Social determinants of health screening in pediatric healthcare settings

PURPOSE OF REVIEW

This article outlines updates in social determinants of health (SDOH) screening practices in pediatric healthcare and community settings. The transition to value-based care and the COVID-19 pandemic have both had significant impacts on screening practices, with implications for providers, communities, and policymakers.

RECENT FINDINGS

The COVID-19 pandemic has exacerbated social needs for vulnerable patients and families, resulting in increased recognition by healthcare teams through screening. Policy frameworks like value-based care that aim to deliver whole-child care in the community are reorienting the logistics of screening, including screening in acute-care settings and community settings. Recent studies on family and provider perspectives should be integrated into screening practices.

SUMMARY

Despite significant advances in and expansion of SDOH screening in the pediatric healthcare setting, there remain limitations and future research needs. More data is needed to evaluate social need screeners and interventions, and determine how healthcare systems, communities, and states can spread and scale such interventions based on outcomes and value measurements. Population-based social indices have the potential to augment individual patient screening, but this remains a future research need.

Socioeconomic Barriers to Randomized Clinical Trial Retention in Patients Treated With Adjuvant Radiation for Early-Stage Breast Cancer

PURPOSE

Socioeconomic barriers contribute to breast cancer clinical trial enrollment disparities. We sought to identify whether socioeconomic disadvantage also is associated with decreased trial retention.

METHODS AND MATERIALS

We performed a secondary analysis of 253 (of 287) patients enrolled in a randomized phase 3 trial of conventionally fractionated versus hypofractionated whole-breast irradiation. The outcome of trial retention versus dropout was defined primarily based on whether the patient completed breast cosmesis outcomes assessment at 3-year follow-up, and secondarily, at 5-year follow-up. Associations of retention with severity of socioeconomic disadvantage, quantified by patients' home neighborhood area deprivation index (ADI) rank (1 [least] to 100 [most deprivation]), were tested using the Kruskal-Wallis test and multivariate logistic regression. Associations of retention with patients' use of social resource assistance were analyzed using the χ² test.

RESULTS

In total, 21.7% (n = 55) of patients dropped out by 3 years and 36.7% (n = 92) by 5 years. Median ADI was 36.5 (interquartile range, 22-57) for retained and 46.0 (interquartile range, 29-60) for dropout patients. Dropout was associated with more severe socioeconomic deprivation (ADI ≥45 vs <45) at 3 years (odds ratio, 3.63; 95% confidence interval, 1.62-8.15; P = .002) and 5 years (odds ratio, 2.55; 95% confidence interval, 1.37-4.76; P = .003). While on study, patients who ultimately dropped out were more likely to require resource assistance for practical (transportation, housing, financial) than psychological needs (distress, grief) or advance care planning (P = .03).

CONCLUSIONS

In this study, ADI was associated with disparities in clinical trial retention of patients with breast cancer receiving adjuvant radiation treatment. Results suggest that developing multidimensional interventions that extend beyond routine social determinants needs screening are needed, not only to enhance initial clinical trial access and enrollment but also to enable robust long-term retention of socioeconomically disadvantaged patients and improve the validity and generalizability of reported long-term trial clinical and patient-reported outcomes.

Incorporating Health Policy and Advocacy Curricula Into Undergraduate Medical Education in the United States

Physicians serve as crucial advocates for their patients. Undergraduate medical education (UME) must move beyond the biomedical model, built upon the perception that health is defined purely in the absence of illness, to also incorporate population health through health policy, advocacy, and community engagement to account for structural and social determinants of health. Currently, the US guidelines for UME lack structured training in health policy or advocacy, leaving trainees ill-equipped to assume their role as physician-advocates or to engage with communities. There is an undeniable need to educate future physicians on legislative advocacy toward improving the social determinants of health through the creation of evidence-based health policy, in addition to training in effective techniques to engage in partnership with the communities in which physicians serve. The authors of this article also present curricular case studies around two programs at their institution that could be used to implement similar programs at other US medical schools.