Sensitivity and Specificity of Real-World Social Factor Screening Approaches

What Does "Palliative Care" Represent in Research Using Secondary Data?

While much research has been done regarding "palliative care" using retrospective cohort studies of large datasets, the data sources may not be capturing specialty palliative care services. This article aims to clarify what source data are used in such studies, how specialty palliative care services are determined to have been provided or not, and mismatches between the nature of the data and the interpretation of researchers. Major US data sources that are examined include cancer registries such as the National Cancer Database; health systems' internal data; state and nation-level hospital admissions data; and claims data from Medicare and commercial payers. Problematic studies are common. Many used cancer registry data and mischaracterized palliative intent for a given cancer treatment as "palliative care services." Dozens relied on the diagnosis code for "encounter for palliative care" which lacks adequate validity for use in research. Researchers, peer-reviewers, and research consumers are cautioned about these potential pitfalls that lead to meaningless or misleading research papers. Suggestions are made regarding more rigorous methods and trustworthy data sources and additional research that can lead to consensus among researchers on these issues.

Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors

OBJECTIVE

Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis.

METHODS

We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023).

RESULTS

Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20).

CONCLUSION

In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review

Household food insecurity has significant negative implications across the lifespan. While routine screening is recommended, particularly in healthcare, guidelines are lacking on selection of screening tools and best-practice implementation across different contexts in non-stigmatizing ways. The objective of this scoping review was to synthesize evidence on household food insecurity screening tools, including psychometrics, implementation in a range of settings, and experiences of carrying out screening or being screened. Four electronic databases were searched for studies in English published from 1990 until June 2023. A total of 58 papers were included, 21 of which focused on tool development and validation, and 37 papers described implementation and perceptions of screening. Most papers were from the USA and described screening in healthcare settings. There was a lack of evidence regarding screening in settings utilized by Indigenous people. The two-item Hunger Vital Sign emerged as the most used and most valid tool across settings. While there is minimal discomfort associated with screening, screening rates in practice are still low. Barriers and facilitators of screening were identified at the setting, system, provider, and recipient level and were mapped onto the COM-B model of behavior change. This review identifies practical strategies to optimize screening and disclosure.

Association of Housing Status With Types of Operations and Postoperative Health Care Utilization

OBJECTIVE

To analyze the association between housing status and the nature of surgical care provided, health care utilization, and operational outcomes.

BACKGROUND

Unhoused patients have worse outcomes and higher health care utilization across multiple clinical domains. However, little has been published describing the burden of surgical disease in unhoused patients.

METHODS

We conducted a retrospective cohort study of 111,267 operations from 2013 to 2022 with housing status documented at a single, tertiary care institution. We conducted unadjusted bivariate and multivariate analyses adjusting for sociodemographic and clinical characteristics.

RESULTS

A total of 998 operations (0.8%) were performed for unhoused patients, with a higher proportion of emergent operations than housed patients (56% vs 22%). In unadjusted analysis, unhoused patients had longer length of stay (18.7 vs 8.7 days), higher readmissions (9.5% vs 7.5%), higher in-hospital (2.9% vs 1.8%) and 1-year mortality (10.1% vs 8.2%), more in-hospital reoperations (34.6% vs 15.9%), and higher utilization of social work, physical therapy, and occupational therapy services. After adjusting for age, sex, comorbidities, insurance status, and indication for operation, as well as stratifying by emergent versus elective operation, these differences went away for emergent operations.

CONCLUSIONS

In this retrospective cohort analysis, unhoused patients more commonly underwent emergent operations than their housed counterparts and had more complex hospitalizations on an unadjusted basis that largely disappeared after adjustment for patient and operative characteristics. These findings suggest issues with upstream access to surgical care that, when unaddressed, may predispose this vulnerable population to more complex hospitalizations and worse longer term outcomes.

Neighborhood social deprivation and healthcare utilization, disability, and comorbidities among young adults with congenital heart defects: Congenital heart survey to recognize outcomes, needs, and well-being 2016-2019

BACKGROUND

Research on the association between neighborhood social deprivation and health among adults with congenital heart defects (CHD) is sparse.

METHODS

We evaluated the associations between neighborhood social deprivation and health care utilization, disability, and comorbidities using the population-based 2016-2019 Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG (CH STRONG) of young adults. Participants were identified from active birth defect surveillance systems in three U.S. sites and born with CHD between 1980 and 1997. We linked census tract-level 2017 American Community Survey information on median household income, percent of ≥25-year-old with greater than a high school degree, percent of ≥16-year-olds who are unemployed, and percent of families with children <18 years old living in poverty to survey data and used these variables to calculate a summary neighborhood social deprivation z-score, divided into tertiles. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) derived from a log-linear regression model with a Poisson distribution estimated the association between tertile of neighborhood social deprivation and healthcare utilization in previous year (no encounters, 1 and ≥2 emergency room [ER] visits, and hospital admission), ≥1 disability, and ≥1 comorbidities. We accounted for age, place of birth, sex at birth, presence of chromosomal anomalies, and CHD severity in all models, and, additionally educational attainment and work status in all models except disability.

RESULTS

Of the 1435 adults with CHD, 43.8% were 19-24 years old, 54.4% were female, 69.8% were non-Hispanic White, and 33.7% had a severe CHD. Compared to the least deprived tertile, respondents in the most deprived tertile were more likely to have no healthcare visit (aPR: 1.5 [95% CI: 1.1, 2.1]), ≥2 ER visits (1.6 [1.1, 2.3]), or hospitalization (1.6 [1.1, 2.3]) in the previous 12 months, a disability (1.2 [1.0, 1.5]), and ≥1 cardiac comorbidities (1.8 [1.2, 2.7]).

CONCLUSIONS

Neighborhood social deprivation may be a useful metric to identify patients needing additional resources and referrals.

Assessing Patient and Community-Level Social Factors; The Synergistic Effect of Social Needs and Social Determinants of Health on Healthcare Utilization at a Multilevel Academic Healthcare System

We investigated the role of both individual-level social needs and community-level social determinants of health (SDOH) in explaining emergency department (ED) utilization rates. We also assessed the potential synergies between the two levels of analysis and their combined effect on patterns of ED visits. We extracted electronic health record (EHR) data between July 2016 and June 2020 for 1,308,598 unique Maryland residents who received care at Johns Hopkins Health System, of which 28,937 (2.2%) patients had at least one documented social need. There was a negative correlation between median household income in a neighborhood with having a social need such as financial resource strain, food insecurity, and residential instability (correlation coefficient: -0.05, -0.01, and - 0.06, p = 0, respectively). In a multilevel model with random effects after adjusting for other factors, living in a more disadvantaged neighborhood was found to be significantly associated with ED utilization statewide and within Baltimore City (OR: 1.005, 95% CI: 1.003-1.007 and 1.020, 95% CI: 1.017-1.022, respectively). However, individual-level social needs appeared to enhance the statewide effect of living in a more disadvantaged neighborhood with the OR for the interaction term between social needs and SDOH being larger, and more positive, than SDOH alone (OR: 1.012, 95% CI: 1.011-1.014). No such moderation was found in Baltimore City. To our knowledge, this study is one of the first attempts by a major academic healthcare system to assess the combined impact of patient-level social needs in association with community-level SDOH on healthcare utilization and can serve as a baseline for future studies using EHR data linked to population-level data to assess such synergistic association.

Health-Related Social Needs: Which Patients Respond to Screening and Who Receives Resources?

BACKGROUND

Health systems are screening patients for health-related social needs (HRSN) but the optimal approach is unknown.

OBJECTIVE

To describe the variation in responding to an HRSN questionnaire delivered via patient portal, and whether referral to and resources provided by social workers differed by response status.

DESIGN

Retrospective observational study.

PARTICIPANTS

Primary care patients with a visit between June 2020 and January 2022.

INTERVENTION

HRSN questionnaire MAIN MEASURES: We identified each patient's index visit (e.g., date of their first questionnaire response for responders or their first visit within the study period for non-responders). Through the EHR, we identified patients' demographic characteristics. We linked the area deprivation index (ADI) to each patient and grouped patients into quintiles. We used multilevel logistic regressions to identify characteristics associated with responding to the questionnaire and, for responders, reporting a need. We also determined if responder status was associated with receiving a social worker referral or receiving a resource. We included patient demographics and ADI quintile as fixed variables and practice site as a random variable.

KEY RESULTS

Our study included 386,997 patients, of which 51% completed at least one HRSN questionnaire question. Patients with Medicaid insurance (AOR: 0.62, 95%CI: 0.61, 0.64) and those who lived in higher ADI neighborhoods had lower adjusted odds of responding (AOR: 0.76, 95% CI: 0.75, 0.78 comparing quintile 5 to quintile 1). Of responders, having Medicaid insurance (versus private) increased the adjusted odds of reporting each of the HRSN needs by two- to eightfold (p < 0.01). Patients who completed a questionnaire (versus non-responders) had similar adjusted odds of receiving a referral (AOR: 0.91, 95% CI: 0.80, 1.02) and receiving a resource from a SW (AOR: AOR: 1.18, 95%CI: 0.79, 1.77).

CONCLUSION

HRSN questionnaire responses may not accurately represent the needs of patients, especially when delivered solely via patient portal.

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.

Automatic extraction of social determinants of health from medical notes of chronic lower back pain patients

OBJECTIVE

We applied natural language processing and inference methods to extract social determinants of health (SDoH) information from clinical notes of patients with chronic low back pain (cLBP) to enhance future analyses of the associations between SDoH disparities and cLBP outcomes.

MATERIALS AND METHODS

Clinical notes for patients with cLBP were annotated for 7 SDoH domains, as well as depression, anxiety, and pain scores, resulting in 626 notes with at least one annotated entity for 364 patients. We used a 2-tier taxonomy with these 10 first-level classes (domains) and 52 second-level classes. We developed and validated named entity recognition (NER) systems based on both rule-based and machine learning approaches and validated an entailment model.

RESULTS

Annotators achieved a high interrater agreement (Cohen's kappa of 95.3% at document level). A rule-based system (cTAKES), RoBERTa NER, and a hybrid model (combining rules and logistic regression) achieved performance of F1 = 47.1%, 84.4%, and 80.3%, respectively, for first-level classes.

DISCUSSION

While the hybrid model had a lower F1 performance, it matched or outperformed RoBERTa NER model in terms of recall and had lower computational requirements. Applying an untuned RoBERTa entailment model, we detected many challenging wordings missed by NER systems. Still, the entailment model may be sensitive to hypothesis wording.

CONCLUSION

This study developed a corpus of annotated clinical notes covering a broad spectrum of SDoH classes. This corpus provides a basis for training machine learning models and serves as a benchmark for predictive models for NER for SDoH and knowledge extraction from clinical texts.

The Impact of Social Determinants of Health in Pediatric Shunted Hydrocephalus

BACKGROUND

Social risk factors have been shown to negatively affect health outcomes in children. However, this has not been characterized regarding pediatric shunted hydrocephalus.

OBJECTIVE

To explore the impact of social risk factors on outcomes in pediatric shunted hydrocephalus with the goal of identifying specific areas of intervention that might improve the outcomes of children undergoing cerebrospinal fluid (CSF) diversion.

METHODS

In an all-payer administrative database, records between January 2010 and October 2020 were analyzed to identify children undergoing CSF shunting procedures. Children with social risk factors were compared with those without regarding rates of infection, shunt-related interventions, and mortality within 5 years of their shunting procedure.

RESULTS

Among the 5420 children who underwent first-time shunting procedures, 263 (4.9%) were identified to have social risk factors. Children with identified social risk factors had increased odds of central nervous system infection (odds ratio [OR] 2.06, 95% CI 1.45-2.91), revision (OR 2.43, 95% I 1.89-3.12), and mortality (OR 2.86, 95% CI 1.23-5.72). The mean numbers of computed tomography studies (14.60 ± 17.78 vs 6.34 ± 6.10), MRI studies (18.76 ± 24.37 vs 7.88 ± 24.37), and shunt series X-rays (17.22 ± 19.04 vs 7.66 ± 8.54) were increased among children with social risk factors.

CONCLUSION

Children with social risk factors had increased rates of central nervous system infection, shunt-related interventions, and mortality within 5 years of CSF shunting. We underscore the importance of characterizing the impact of social risk factors in specific conditions, such as pediatric shunted hydrocephalus, and look to future directions aimed to mitigate these risk factors with coordination and direction of individualized resources, encouragement of advocacy, and community partnership.

Association of Coded Housing Instability and Hospitalization in the US

IMPORTANCE

Housing instability and other social determinants of health are increasingly being documented by clinicians. The most common reasons for hospitalization among patients with coded housing instability, however, are not well understood.

OBJECTIVE

To compare the most common reasons for hospitalization among patients with and without coded housing instability.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, retrospective study identified hospitalizations of patients between age 18 and 99 years using the 2017 to 2019 National Inpatient Sample. Data were analyzed from May to September 2022.

EXPOSURES

Housing instability was operationalized using 5 International Classification of Diseases, 10th Revision, Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; and other related problems.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was reason for inpatient admission. Bivariate comparisons of patient characteristics, primary diagnoses, length of stay, and hospitalization costs among patients with and without coded housing instability were performed.

RESULTS

Among the 87 348 604 hospitalizations analyzed, the mean (SD) age was 58 (20) years and patients were more likely to be women (50 174 117 [57.4%]) and White (58 763 014 [67.3%]). Housing instability was coded for 945 090 hospitalizations. Hospitalized patients with housing instability, compared with those without instability, were more likely to be men (668 255 patients with coded instability [70.7%] vs 36 506 229 patients without [42.3%]; P < .001), younger (mean [SD] age 45.5 [14.0] vs 58.4 [20.2] years), Black (235 355 patients [24.9%] vs 12 929 158 patients [15.0%]), Medicaid beneficiaries (521 555 patients [55.2%] vs 15 541 175 patients [18.0%]), uninsured (117 375 patients [12.4%] vs 3 476 841 patients [4.0%]), and discharged against medical advice (28 890 patients [8.4%] vs 451 855 patients [1.6%]). The most common reason for hospitalization among patients with coded housing instability was mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%]), which cost a total of $3.5 billion. Other common reasons included injury (69 270 patients [7.3%]) and circulatory system diseases (64 700 patients [6.8%]). Coded housing instability was also significantly associated with longer mean (SD) hospital stays (6.7 [.06] vs 4.8 [.01] days) and a cost of $9.3 billion. Hospitalized patients with housing instability had 18.6 times greater odds of having a primary diagnosis of mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%] vs 4 470 675 patients [5.2%]; odds ratio, 18.56; 95% CI, 17.86 to 19.29).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, hospitalizations among patients with coded housing instability had higher admission rates for mental, behavioral, and neurodevelopmental disorders, longer stays, and increased costs. Findings suggest that efforts to improve housing instability, mental and behavioral health, and inpatient hospital utilization across multiple sectors may find areas for synergistic collaboration.