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Arias F, Dufour AB, Jones RN, Alegria M, Fong TG, Inouye SK. Social determinants of health and incident postoperative delirium: Exploring key relationships in the SAGES study. J Am Geriatr Soc 2024; 72:369-381. [PMID: 37933703 PMCID: PMC10922227 DOI: 10.1111/jgs.18662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Examining the associations of social determinants of health (SDOH) with postoperative delirium in older adults will broaden our understanding of this potentially devastating condition. We explored the association between SDOH factors and incident postoperative delirium. METHODS A retrospective study of a prospective cohort of patients enrolled from June 18, 2010, to August 8, 2013, across two academic medical centers in Boston, Massachusetts. Overall, 560 older adults age ≥70 years undergoing major elective non-cardiac surgery were included in this analysis. Exposure variables included income, lack of private insurance, and neighborhood disadvantage. Our main outcome was incident postoperative delirium, measured using the Confusion Assessment Method long form. RESULTS Older age (odds ratio, OR: 1.01, 95% confidence interval, CI: 1.00, 1.02), income <20,000 a year (OR: 1.12, 95% CI: 1.00, 1.26), lack of private insurance (OR: 1.19, 95% CI: 1.04, 1.38), higher depressive symptomatology (OR: 1.02, 95% CI: 1.01, 1.04), and the Area Deprivation Index (OR: 1.02, 95% CI: 1.01, 1.04) were significantly associated with increased risk of postoperative delirium in bivariable analyses. In a multivariable model, explaining 27% of the variance in postoperative delirium, significant independent variables were older age (OR 1.01, 95% CI 1.00, 1.02), lack of private insurance (OR 1.18, 95% CI 1.02, 1.36), and depressive symptoms (OR 1.02, 95% CI 1.00, 1.03). Household income was no longer a significant independent predictor of delirium in the multivariable model (OR:1.02, 95% CI: 0.90, 1.15). The type of medical insurance significantly mediated the association between household income and incident delirium. CONCLUSIONS Lack of private insurance, a social determinant of health reflecting socioeconomic status, emerged as a novel and important independent risk factor for delirium. Future efforts should consider targeting SDOH factors to prevent postoperative delirium in older adults.
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Affiliation(s)
- Franchesca Arias
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32608, USA
| | - Alyssa B. Dufour
- Harvard Medical School, Boston, MA 02131, USA
- Biostatistics and Data Sciences, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02131, USA
| | - Richard N. Jones
- Department of Psychiatry and Human Behavior, Brown University, Warren Alpert Medical School, Providence, RI 02912, USA
| | - Margarita Alegria
- Disparities Research Unit, Massachusetts General Hospital, Boston, MA 02131, USA
- Department of Medicine and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02131, USA
| | - Tamara G. Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
| | - Sharon K. Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research at the Hebrew SeniorLife, Boston, MA 02131, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA 02131, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02131, USA
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Schiefelbein AM, Krebsbach JK, Taylor AK, Zhang J, Haimson CE, Trentham-Dietz A, Skala MC, Eason JM, Weber SM, Varley PR, Zafar SN, LoConte NK. Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin. WMJ : OFFICIAL PUBLICATION OF THE STATE MEDICAL SOCIETY OF WISCONSIN 2022; 121:77-93. [PMID: 35857681 PMCID: PMC9354557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients. METHODS We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models. RESULTS The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09). CONCLUSION Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.
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Affiliation(s)
| | - John K Krebsbach
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Amy K Taylor
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Jienian Zhang
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Chloe E Haimson
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amy Trentham-Dietz
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Melissa C Skala
- Morgridge Institute for Research, Madison, Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - John M Eason
- Department of Sociology, University of Wisconsin-Madison, Madison, Wisconsin
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Community and Environmental Sociology, University of Wisconsin-Madison, Madison, Wisconsin
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sharon M Weber
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Patrick R Varley
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Surgical Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Syed N Zafar
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
- Department of Surgical Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Noelle K LoConte
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison Wisconsin,
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
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Jaffe TA, Wang D, Loveless B, Lai D, Loesche M, White B, Raja AS, He S. A Scoping Review of Emergency Department Discharge Risk Stratification. West J Emerg Med 2021; 22:1218-1226. [PMID: 34787544 PMCID: PMC8597698 DOI: 10.5811/westjem.2021.6.52969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/25/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge. METHODS We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified. RESULTS PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs. CONCLUSION Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients' needs upon ED discharge.
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Affiliation(s)
- Todd A Jaffe
- Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts
| | - Daniel Wang
- Kansas City University School of Medicine, Kansas City, Missouri
| | - Bosten Loveless
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Debbie Lai
- University College of London, Division of Psychology and Language Sciences, London, England
| | - Michael Loesche
- Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts
| | - Benjamin White
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Ali S Raja
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Shuhan He
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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Ordonez E, Dowdell K, Navejar N, Dongarwar D, Itani A, Salihu H. An Assessment of the Social Determinants of Health in an Urban Emergency Department. West J Emerg Med 2021; 22:890-897. [PMID: 35354001 PMCID: PMC8328163 DOI: 10.5811/westjem.2021.4.50476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/03/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: Social determinants of health (SDOH) have significant impacts on patients who seek care in the emergency department (ED). We administered a social needs screening tool and needs assessment survey to assess SDOH and evaluate for trends in the population of patients visiting our ED.
Methods: A survey was distributed via convenience sampling to adult ED patients to capture self-reported demographic information and data about social needs. We categorized the questions related to SDOH based on the International Classification of Diseases, Tenth Revision, Clinical Modification coding format and created a composite variable called “SDOH Strata” based on the SDOH Index scores (0-5-low, 6-10-middle, or ≥11-high). We conducted bivariate analyses using the sociodemographic characteristics of the patients and their SDOH Strata using Fisher’s exact test. We then conducted multinomial logistic regression to examine the association between the patients’ sociodemographic characteristics and the SDOH Strata.
Results: A total of 269 surveys were collected. We observed that Hispanic/Latino patients were more than two times as likely (odds ratio: 2.04, 95% confidence interval [CI], 1.12,-6.51) to be in the higher impact stratum than in the lower impact stratum. Those who were undocumented had 3.43 times increased adjusted odds (95% CI, 1.98, 9.53) of being in the higher than the lower impact stratum compared to US citizens. Additionally, people speaking Spanish as their primary language were 5.16 times as likely to be in the higher impact stratum compared to the reference (English-speaking and lower impact stratum).
Conclusion: In our patient population, patients noted to have the highest impact burden of the SDOH were those who identified as Hispanic/Latino, Spanish-speaking, and undocumented immigrant status.
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Affiliation(s)
- Edgardo Ordonez
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas; Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Katherine Dowdell
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas
| | - Natasha Navejar
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Deepa Dongarwar
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Aya Itani
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas
| | - Hamisu Salihu
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
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Walter LA, Schoenfeld EM, Smith CH, Shufflebarger E, Khoury C, Baldwin K, Hess J, Heimann M, Crosby C, Sontheimer SY, Gragg S, Hand D, McIlwain J, Greene C, Skains RM, Hess EP. Emergency department-based interventions affecting social determinants of health in the United States: A scoping review. Acad Emerg Med 2021; 28:666-674. [PMID: 33368833 PMCID: PMC11019818 DOI: 10.1111/acem.14201] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED-based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED-based interventions aimed at mitigating negative SDoH. METHODS We conducted a scoping review to identify and characterize peer-reviewed research articles that report ED-based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy. RESULTS A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%). CONCLUSION Emergency department-based interventions that address seven different SDoH domains have been reported in the peer-reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda.
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Affiliation(s)
- Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate Medical Cente, Springfield, Massachusetts, USA
| | - Catherine H Smith
- Lister Hill Library, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erin Shufflebarger
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Khoury
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katherine Baldwin
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Jennifer Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Heimann
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cameron Crosby
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sylvia Y Sontheimer
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Stephen Gragg
- ChristianaCare EM/IM Residency Program, Newark, Delaware, USA
| | - Delissa Hand
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph McIlwain
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Christopher Greene
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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