A systematic review of reasons for and against asking patients about their socioeconomic contexts

Biomarkers and Social Determinants in Atherosclerotic Arterial Diseases: A Scoping Review

BACKGROUND

Arterial diseases like coronary artery disease (CAD), carotid stenosis (CS), peripheral artery disease (PAD), and abdominal aortic aneurysm (AAA) have high morbidity and mortality, making them key research areas. Their multifactorial nature complicates patient treatment and prevention. Biomarkers offer insights into the biochemical and molecular processes, while social factors also significantly impact patients' health and quality of life. This scoping review aims to search the literature for studies that have linked the biological mechanisms of arterial diseases through biomarkers with social issues and to analyze them, supporting the interdependence of biological and social sciences.

METHODS

After a rigorous selection process, adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for Scoping Reviews, 30 articles were identified through Scopus, Web of Science, and PubMed. Inclusion and exclusion criteria were based on the population, intervention, comparator, outcome, time, and setting framework. Inclusion criteria were studies involving human subjects that explored the relationships among arterial diseases, biomarkers, and psychosocial factors, with no restrictions on publication date. Nonhuman studies, purely biological or medical analyses without psychosocial dimensions, and non-English publications were excluded. Eligible study types included experimental, observational, and review articles published in peer-reviewed journals. Data extraction focused on study characteristics, such as authors, publication year, country, methods, population, and findings. Results were synthesized narratively, as this format was deemed the most suitable for summarizing diverse findings. The quality or methodological rigor of the included studies was not formally assessed, consistent with the scoping review methodology.

RESULTS

In CAD, biomarkers such as high-sensitivity C-reactive protein are strongly associated with psychological stress, whereas lipoprotein (a) and the apolipoprotein B/apolipoprotein A1 ratio reflect lipid profiles that are influenced by socioeconomic factors and ethnicity. In CS, increased carotid intima-media thickness is linked to psychiatric conditions like attention deficit/hyperactivity disorder, and heat shock protein-70 levels are associated with socioeconomic status and gender. In PAD, inflammatory markers, including interleukin-6, intracellular adhesion molecule-1, and high-sensitivity C-reactive protein, mediate the connection between depression and disease severity, with gender and ethnicity influencing the expression of biomarkers and clinical outcomes. In AAA, factors like smoking and exposure to air pollution have increased matrix metalloproteinase levels and other inflammatory markers. Additionally, estradiol provides partial protection in women, underscoring the role of hormones and environmental influences in disease progression. Social determinants such as socioeconomic status, healthcare access, and ethnicity significantly affect biomarker levels and arterial disease progression.

CONCLUSIONS

These findings are crucial for the assumption that social determinants of health modulate the levels of inflammatory biomarkers involved in the progression of arterial diseases such as CAD, CS, PAD, and AAA. This highlights the need to integrate highly predictive mathematical systems into clinical practice, combining biological sciences with social sciences to achieve advanced standards in precision medicine. However, further studies are needed to validate these approaches fully.

Social Determinants of Health and 30-Day Readmission After Acute Myocardial Infarction in the REGARDS Study

BACKGROUND

Social determinants of health (SDOH) may influence 30-day readmission or emergency department (ED) use following acute myocardial infarction (AMI) hospitalizations. Understanding this relationship will promote the development of interventions and policies to reduce readmissions.

OBJECTIVES

The aim of the study was to test associations between SDOH and readmission after AMI.

METHODS

In this cross-sectional study, we analyzed 753 adults ≥65 years from the Reasons for Geographic and Racial Differences in Stroke study discharged after an AMI between 2003 and 2019. Participants were categorized into 3 groups (0/1, 2, and 3+) based on the number of SDOHs. Poisson models were used to determine relative risks (RRs) and corresponding 95% CI for the associations between SDOH and risk of readmission/ED visit.

RESULTS

Of participants, 39.1% (295/753) were women, 27.5% (207/753) were Black, and the median age was 77 years (72-82 years). There were 219 (29.1%) individuals with readmission/ED visit. Of 612 participants with validated SDOH counts, 273 (44.6%) had 0/1 SDOH, 117 (19.1%) had 2 SDOH, and 222 (36.3%) had 3+ SDOH. After adjusting for age and region, increasing number of SDOHs was associated with elevated readmission/ED visit risk (2 SDOH: RR: 1.15; 95% CI: 0.83-1.60; 3+ SDOH: RR: 1.56; 95% CI: 1.20-2.01; P trend = 0.001). Similar results were observed in the fully adjusted model (2 SDOH: RR: 1.12; 95% CI: 0.81-1.56; 3+ SDOH: RR: 1.37; 95% CI: 1.04-1.80; P trend = 0.026).

CONCLUSIONS

A cumulative burden of SDOHs is associated with an increased risk of readmission/ED visits after AMI hospitalization. SDOH burden may be a useful approach in identifying individuals presenting with AMI who are most vulnerable for readmission.

Effectiveness of clinical healthcare interventions for enhancing the work participation of patients with various health conditions: a synthesis of systematic reviews

OBJECTIVES

This objectives of this study were to determine the effectiveness of clinical healthcare interventions designed for improving the work participation of patients with various health conditions and identify promising elements within these interventions.

DESIGN

A systematic literature search was conducted, and a synthesis of systematic reviews (SRs) was performed.

DATA SOURCES

MEDLINE, Embase, Cochrane Library and CINAHL were searched for articles published from January 2012 to December 2023.

ELIGIBILITY CRITERIA

SRs of randomised controlled trials evaluating the effectiveness of interventions that aimed at improving work participation initiated within clinical healthcare in patients being treated for various health conditions were included.

DATA EXTRACTION AND SYNTHESIS

Two authors independently used standardised methods to search and select SRs, and extract data. Our primary outcome was work participation, which could include return-to-work rate or sick leave duration. We were interested in both short-, medium-, as well as long-term outcomes. Risk of bias was assessed using the AMSTAR-2 tool. We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to evaluate the certainty of the evidence and findings were summarised in GRADE evidence profiles. We used a deductive synthesis to identify promising intervention elements.

RESULTS

The health conditions included in the selected SRs were cancer, chronic low back and musculoskeletal pain, coronary heart disease, inflammatory arthritis, complaints of the lumbopelvic region during pregnancy, stroke and traumatic brain injury. Across health conditions, many interventions trended towards small, favourable effects. Moderately certain evidence showed that multidisciplinary and physical interventions enhance work participation at 12 months for people with cancer (risk ratio (RR) 1.23, 95% CI 1.09 to 1.33 and RR 1.23, 95% CI 1.08 to 1.39, respectively), and that multidisciplinary interventions reduce the days of return to work compared with usual care for people with coronary heart disease (40.77 days lower than control, 95% CI -67.19 to -14.35). Low-certainty evidence suggested that multidisciplinary interventions may enhance work participation at 12 months for people with coronary heart disease (RR 1.56, 95% CI 1.23 to 1.98) and reduce the number of sick leave days at 12 months for people with chronic low back pain (82, IQR 51 to 164 vs 175, IQR 91 to 365; p=0.003). Promising elements included (psycho)education, cognitive-behavioural therapy, psychosocial support, group and vocational counselling and physical training.

CONCLUSIONS

There is considerable overlap in clinical healthcare interventions that aim to enhance work participation for patients across health conditions. Although their effects on work participation vary, some conditions show favourable response to multidisciplinary interventions. More evidence is needed on developing tailored interventions and evaluating their cost-effectiveness.

PROSPERO REGISTRATION NUMBER

CRD42022346552.

"People Need to Know; We're Part of the Community. We're Here.": Examining Experiences of Sharing Demographic Information for a Community-Based Diabetes Prevention Program

BACKGROUND

Collecting demographic data is critical for identifying inequities in healthcare services and delivery. Inaccurate collection of demographic data can make developing equitable health interventions and improving reach of existing interventions difficult. This study aimed to (a) examine experiences in completing a community-based type 2 diabetes prevention program Small Steps for Big Changes (SSBC) demographic questionnaire (SSBC-DQ) among adults from equity-owed groups, and (b) assess recommendations for improvement to the questionnaire.

METHODS

Adults with no prior involvement in SSBC were recruited. Participants completed the SSBC-DQ online and then engaged in one-on-one structured interviews. Interview data was analyzed using interpretive description and coded using the APEASE criteria.

RESULTS

Twelve participant interviews were included in analysis. Five principle themes were developed to capture the experiences of completing the SSBC-DQ: representation, comprehension, demographics are an emotional experience, the role that privilege plays, and beliefs about demographic data. Sixty suggested changes were coded using the APEASE criteria; six suggestions met the criteria for implementation, 20 did not meet the criteria, and 34 required further discussion with the research team.

CONCLUSIONS

Results from this study illustrate that people's lived experiences can drive their reactions and interpretations to demographic questionnaires. Based on end-user suggestions, SSBC made changes to its demographic questionnaire to be more inclusive. Having a demographic questionnaire that is more inclusive can help SSBC better understand what populations it is and is not reaching in an acceptable and inclusive manner. This will help inform future directions regarding evaluating program reach and equity.

Regional socioeconomic characteristics and density of general practitioners in Germany: A nationwide cross-sectional and longitudinal spatial analysis

OBJECTIVES

Limited healthcare availability impacts population health. Regional disparities in GP density across Germany raise questions about their association with regional socioeconomic characteristics.

STUDY DESIGN

This longitudinal nationwide ecological German study used regional data at the county level (n = 401) from 2015 to 2019 provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). The outcome was general practitioners (GPs) density, defined as the number of GPs per 10,000 inhabitants.

METHODS

Univariate Moran's I, cluster analysis (LISA), and spatial lag of X (SLX) models were employed to analyse the spatial distribution of GP density and its correlation with various regional socioeconomic characteristics from a cross-sectional and longitudinal perspective.

RESULTS

In contrast to the univariate analysis, rural counties showed the highest GP density the multivariate model. Several counties were identified as embedded in low- or high-GP-density clusters. In 2015 and 2019, larger household size (2015: std. β = -2.31, p = 0.021; 2019: std. β = -4.14, p < 0.001) and higher unemployment rate (2015: std. β = -2.84, p = 0.005; 2019: std. β = -5.47, p < 0.001) were associated with lower GP density. In the longitudinal model, a greater increase in the unemployment rate was related to a greater decrease in GP density (std. β = -2.17, p = 0.030).

CONCLUSION

A higher regional unemployment rate is linked to lower GP availability in Germany, and a greater increase in the unemployment rate was related to a greater decrease in GP availability over time. This necessitates policy intervention to avoid socioeconomic disparities in GP care.

Clinical Work-Integrating Care in Current Practice: A Scoping Review

PURPOSE

Clinical work-integrating care (CWIC) refers to paying attention to work participation in a clinical setting. Working patients may benefit from CWIC. The purpose of this study is to explore the extent and nature to which medical specialists provide CWIC and what policies and guidelines oblige or recommend specialists to do.

METHODS

A scoping review was conducted. The databases MEDLINE, EMBASE, Psychinfo, CINAHL, and Web of Science were searched for studies on the extent and nature of CWIC and supplemented by gray literature on policies and guidelines. Six main categories were defined a priori. Applying a meta-aggregative approach, subcategories were subsequently defined using qualitative data. Next, quantitative findings were integrated into these subcategories. A separate narrative of policies and guidelines using the same main categories was constructed.

RESULTS

In total, 70 studies and 55 gray literature documents were included. The main findings per category were as follows: (1) collecting data on the occupation of patients varied widely; (2) most specialists did not routinely discuss work, but recent studies showed an increasing tendency to do so, which corresponds to recent policies and guidelines; (3) work-related advice ranged from general advice to patient-physician collaboration about work-related decisions; (4) CWIC was driven by legislation in many countries; (5) specialists sometimes collaborated in multidisciplinary teams to provide CWIC; and (6) medical guidelines regarding CWIC were generally not available.

CONCLUSION

Medical specialists provide a wide variety of CWIC ranging from assessing a patient's occupation to extensive collaboration with patients and other professionals to support work participation. Lack of medical guidelines could explain the variety of these practices.

A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study

INTRODUCTION

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them.

METHODS

Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis.

RESULTS

Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication.

CONCLUSION

SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

Applying an equity lens to social prescribing

BACKGROUND

Social prescribing is often described as an intervention that can help reduce health inequalities yet there is little evidence exploring this. This study aimed to assess the feasibility of accessing and analysing social prescribing (SP) service user data to demonstrate the impact of SP on health inequalities.

METHODS

The sample size consisted of records for 276 individuals in Site 1 and 1644 in Site 2. Descriptive analyses were performed to assess the characteristics of people accessing SP, the consistency of data collected and the missingness across both sites.

RESULTS

Both sites collected basic demographic data (age gender, ethnicity and deprivation). However, data collection was inconsistent; issues included poor recording of ethnicity in Site 2, and for both sites, referral source data and health and well-being outcome measures were missing. There was limited data on the wider determinants of health. These data gaps mean that impacts on health inequalities could not be fully explored.

CONCLUSIONS

It is essential that SP data collection includes information on user demographics and the wider determinants of health in line with PROGRESS Plus factors. Considering equity around who is accessing SP, how they access it and the outcomes is essential to evidencing how SP affects health inequalities and ensuring equitable service delivery.

Screening for adverse social conditions in child healthcare settings: protocol for a systematic review

INTRODUCTION

Adverse social conditions affect children's development and health outcomes from preconception throughout their life course. Early identification of adverse conditions is essential for early support of children and their families. Healthcare contacts with children provide a unique opportunity to screen for adverse social conditions and to take preventive action to identify and address emerging, potentially harmful or accumulating social problems. The aim of our study is to identify and describe available screening tools in outpatient and inpatient healthcare settings that capture social conditions that may affect children's development, health or well-being.

METHODS AND ANALYSIS

We will conduct a systematic review and will report the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. A systematic search of three databases (PubMed (Ovid), PsycInfo (EBSCOhost) and Web of Science Core Collection (Clarivate)) for English-language and German-language articles from 2014 to date will be conducted. We will include peer-reviewed articles that develop, describe, test or use an instrument to screen children for multiple social conditions in paediatric clinics or other outpatient or inpatient child healthcare settings. Key study characteristics and information on screening tools will be extracted and presented in structured tables to summarise the available evidence. We will assess the methodological quality of the instruments with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as we will not be collecting any personal data. Dissemination will consist of publications, presentations, and other knowledge translation activities.

Diabetes control in public assistance recipients and free/low-cost medical care program beneficiaries in Japan: a retrospective cross-sectional study

Introduction

Previous research has highlighted the association between socioeconomic factors and diabetes management. This study aimed to elucidate the blood glucose control status among individuals with low income (ie, recipients of public assistance (PARs) and free/low-cost medical care (FLCMC) programme beneficiaries) and to investigate the effects of public subsidies for medical expenses on treatment adherence among low-income patients with diabetes.

Methods

We conducted a secondary analysis of medical records from 910 outpatients with diabetes who underwent pharmacological treatment for >90 days. Data on predictive variables, such as glycated haemoglobin (HbA1c) level and control variables, including sex, age and insurance type, were obtained retrospectively. The HbA1c levels among public health insurance (PHI)-only beneficiaries, FLCMC programme beneficiaries and PARs were compared using logistic regression analysis.

Results

The analysis included 874 individuals, among whom the majority were men (61.7%) and aged≥65 years (58.4%). Logistic regression analysis revealed that among individuals aged ˂65 years, the adjusted ORs for HbA1c levels above 9% were significantly higher in FLCMC programme beneficiaries (OR=5.37, 95% CI: 2.23 to 12.82) and PARs (OR=5.97, 95% CI: 2.91 to 12.74) than in PHI-only beneficiaries. Among patients aged ˂65 years with HbA1c levels above 7%, the adjusted OR was significantly higher in FLCMC programme beneficiaries (OR=3.82, 95% CI: 1.65 to 10.43) than in PHI-only beneficiaries. Additionally, the adjusted OR was significantly higher in FLCMC programme beneficiaries aged ˂65 years (OR=2.57, 95% CI: 1.02 to 7.44) than in PARs.

Conclusions

This study highlights the predictive value of public assistance or the FLCMC programme for poor blood glucose control and suggests the inadequacy of current medical expense subsidies to eliminate health disparities in diabetes control.

Integration of social determinants of health information within the primary care electronic health record: a systematic review of patient perspectives and experiences

BACKGROUND

Social determinants of health (SDOH) are the non-medical factors that impact health. Although geographical measures of deprivation are used, individual measures of social risk could identify those most at risk and generate more personalised care and targeted referrals to community resources. We know SDOH are important to health care, but it is not yet known whether their collection via the electronic health record (EHR) is acceptable and useful from the patient perspective.

AIM

To synthesise relevant literature to explore patient perspectives on integrating information about SDOH into primary care EHRs, and the opportunities and challenges of its implementation in a general practice setting.

DESIGN & SETTING

Systematic review of primary care-based qualitative and mixed-method studies using thematic framework analysis.

METHOD

Key databases were searched for articles reporting patient perspectives of SDOH collection within the primary care EHR. Qualitative and mixed-methods studies written in English were included. A framework analysis was conducted to identify themes.

RESULTS

From 14 included studies, the following five main themes were identified: rationale for SDOH screening and the anticipated outcomes; impact of the provider-patient relationship on patient perceptions; data, which included privacy concerns; screening process and referral; and recommendations for future research.

CONCLUSION

Integration of information on SDOH into the EHR appears acceptable to patients. This review has added to the discussion of whether and how to implement SDOH screening and referral programmes into UK primary care systems.

Making ends meet - relating a self-reported indicator of financial hardship to health status

BACKGROUND

Area-based index of multiple deprivation (IMD) indicators of financial hardship lack individual specificity and sensitivity. This study compared self-reports of hardship with area measures in relation to health status.

METHODS

Interviews in one London Borough, reported financial hardship and health status. Associations of health status with most and least deprived quintiles of the IMD 2015 were compared with self-reported hardship; always or sometimes 'having difficulty making ends meet at the end of the month' in relation to never.

RESULTS

1024 interviews reported hardship status in 1001 (98%). 392 people (39%) reported they 'always' or 'sometimes' had hardship. In multivariate analysis, self-reported hardship was more strongly associated with smoking; odds ratio = 5.4 (95% CI: 2.8-10.4) compared with IMD, odds ratio = 1.9 (95% CI: 1.2-3.2). Health impairment was also more likely with self-reported hardship, odds ratio = 11.1 (95% CI: 4.9-25.4) compared with IMD; odds ratio = 2.7 (95% CI: 1.4-5.3). Depression was similarly related; odds ratio = 2.4 (95% CI: 1.0-5.6) and 2.7 (95% CI: 1.2-6.6), respectively.

CONCLUSIONS

Self-reported hardship was more strongly related to health status than area-based indicators. Validity and implementation in routine health care settings remains to be established.

The feasibility of identifying health inequalities in social prescribing referrals and declines using primary care patient records

Background

Social prescribing (SP) is part of universal personalised care and available to everyone in the UK National Health Service. However, emerging evidence suggests access disparities in social prescribing. This study aimed to investigate the feasibility of using primary care records to access and analyse data on social prescribing. Our secondary aim was to compare characteristics of patients who are offered referral, referred to or decline referral for social prescribing to explore possible inequalities in access to social prescribing.

Methods

Patient records (n=3086) were extracted from 11 GP practices across Northwest England for accepted, offered and declined social prescribing referrals. Patient demographics collected included sex, age, ethnicity, mental and physical health diagnoses. Patient characteristics in social prescribing referrals were compared to the overall practice population (practice information from Public Health England). Referral and decline rates were compared by group (e.g. male/female decline rates).

Results

GP referral data showed inconsistent recording of wider determinants of health. Patient age, sex and mental and physical health conditions were consistently recorded. Other variables (marital status, interpreter need, education, disability, sexual orientation, non-English language, nationality) were recorded only sporadically and could not be used for analysis. Practices varied in referral patterns. Our preliminary findings identified under-referring of younger age groups and Asians, and higher declined referrals among individuals with physical health diagnoses.

Conclusions

Recording discrepancies meant that many patient factors could not be used to identify trends in social prescribing referrals and declines and assess equity. Primary care data recording must be consistent to understand SP referral trends and inequalities relating to the wider determinants of health. Preliminary results suggest some patient groups may be underrepresented in SP referrals, however this requires further investigation.

"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.

Should a patient's socioeconomic status count in decisions about treatment in medical care? A longitudinal study of Norwegian doctors

AIMS

The major causes of social inequalities in health are found outside of healthcare. However, healthcare can also play a role in maintaining, reducing, or reinforcing inequality. We present and discuss results from a panel study of doctors' views on whether and how socioeconomic factors should play a role in clinical decision making.

METHODS

The panel comprised a representative sample of Norwegian doctors, established in 1994. For the current study, the doctors received postal questionnaires in 2008, 2012 and 2016. Data were analysed using descriptive statistics, correlation analysis, factor analysis and mixed models for repeated measurements.

RESULTS

The sample sizes were 1072 (65%), 1279 (71%) and 1605 (73%), respectively. The doctors were increasingly positive towards considering socioeconomic factors, and reported giving more time and advice and asking for less pay to compensate for unfavorable socioeconomic factors. General practitioners were more likely to consider socioeconomic factors and changed their practice accordingly compared to other clinicians. The percentage of doctors who agreed that different amounts of resources should be used to obtain similar health effects was high and increased over time.

CONCLUSIONS

Increasingly more doctors are willing to consider patients' socioeconomic factors in clinical care. This could be contrary to professional ethics, in which only medical need should count. However, it depends on how 'need' is interpreted. As treatment outcomes partly depend on non-medical factors, socioeconomic factors should be considered because they influence patients' ability to benefit from medical care. Equality requires mitigating factors with negative impacts on health outcomes.

Collection and Use of Social Determinants of Health Data in Inpatient General Internal Medicine Wards: A Scoping Review

BACKGROUND

There is growing interest in incorporating social determinants of health (SDoH) data collection in inpatient hospital settings to inform patient care. However, there is limited information on this data collection and its use in inpatient general internal medicine (GIM). This scoping review sought to describe the current state of the literature on SDoH data collection and its application to patient care in inpatient GIM settings.

METHODS

English-language searches on MedLine, Embase, Web of Science, CINAHL, Cochrane, and PsycINFO were conducted from 2000 to April 2021. Studies reporting systematic data collection or use of at least three SDoH, sociodemographic, or social needs variables in inpatient hospital GIM settings were included. Four independent reviewers screened abstracts, and two reviewers screened full-text articles.

RESULTS

A total of 8190 articles underwent abstract screening and eight were included. A range of SDoH tools were used, such as THRIVE, PRAPARE, WHO-Quality of Life, Measuring Health Equity, and a biopsychosocial framework. The most common SDoH were food security or malnutrition (n=7), followed by housing, transportation, employment, education, income, functional status and disability, and social support (n=5 each). Four of the eight studies applied the data to inform patient care, and three provided community resource referrals.

DISCUSSION

There is limited evidence to guide the collection and use of SDoH data in inpatient GIM settings. This review highlights the need for integrated care, the role of the electronic health record, and social history taking, all of which may benefit from more robust SDoH data collection. Future research should examine the feasibility and acceptability of SDoH integration in inpatient GIM settings.

How do medical students learn in an online community diagnostics program?

BACKGROUND

The need to engage medical students in understanding the social and environmental determinants of health in disparate communities is increasing. However, previous reviews have noted the limited community diagnosis programs and program evaluation. Given the feasibility of the programs, it is expected to be widely available online. Therefore, this study used a realist approach to identify learning patterns through an online community diagnosis program, namely context (C), mechanism (M), and outcomes (O) patterns.

METHODS

A 2-week general medicine clinical practice program was conducted for 4^th- and 5^th-year medical students at a medical university in Japan. The program included a one-hour zoom-based lecture, feedback for students on their presentations on community diagnosis, and a structural report on community diagnosis. We developed the program based on variation theory, which views discernment and variation in situations having time, space, and social dimensions as core learning. The students' reflections on their learning through the program were thematically analyzed through CMO perspectives. The realist approach used in the online diagnosis program evaluation allows us to explore, test, and refine what mechanisms work under what conditions (context) and with what interventions (including opportunities and resources), from which we can describe iteratively explainable results.

RESULTS

First, the medical students, who spent most of their time in the limited residential areas they lived in, discovered the characteristics of their own community by discovery learning and comparison among peers. Second, they increased their intrinsic interest in the community by discerning specific issues in their familiar community through community diagnosis. Third, they valued community diagnosis by identifying relationships between local data on health issues under their learning responsibility. Fourth, they become more flexible in their thinking and created new knowledge that would fit the local community, and their reflection on themselves was encouraged.

CONCLUSION

In this online community diagnosis program, medical students learned about the community through four types of learning patterns. Medical students may develop an understanding of community with interest using variation theory as a program development perspective and cognitive flexibility theory surrounding the essential ambiguity and abstraction of community.

Impact of eConsults on Clinical Care in Primary Care: A Cross-Sectional Analysis of Primary Care Provider Behavior

INTRODUCTION/OBJECTIVES

Asynchronous electronic consultations (eConsults) support primary care providers (PCPs) by providing rapid specialist feedback and improve medically underserved patients' access to care.

METHODS

This cross-sectional study assessed all eConsults requested over a one-year period at a multi-site federally qualified health center in Texas. We analyzed eConsult content and quality and conducted chart reviews for a randomly selected subsample (n = 100) to determine whether PCPs implemented specialists' recommendations within 90 days. Semi-structured interviews with PCPs assessed their ability and willingness to follow recommendations.

RESULTS

There were 367 eConsults submitted by 25 PCPs across 15 adult medical and surgical specialties. Of the 100 charts reviewed n = 77 (77.0%) contained documentation indicating that the PCP had followed at least 1 of the specialist's recommendations within 90 days. In two-thirds of the cases (n = 66, 66%) the reviewing specialist indicated that a face-to-face referral was not needed. PCPs were most likely to follow recommendations for new medications and least likely to document that they had obtained additional patient history. PCPs noted that they were sometimes unable to follow recommendations when patients could not afford or access treatment or did not return for follow up care, or when they felt that the specialist did not address their specific question.

CONCLUSIONS

eConsults delivered to medically underserved patients in primary care help PCPs provide timely care for their patients. PCPs utilized a broad range of eConsult specialties and generally implemented eConsult specialists' recommendations within 90 days.

Process evaluation of the 'Grip on Health' intervention in general and occupational health practice

BACKGROUND

For working patients with a lower socioeconomic position, health complaints often result from a combination of problems on multiple life domains. To prevent long-term health complaints and absence from work, it is crucial for general and occupational health professionals to adopt a broad perspective on health and to collaborate when necessary. This study aimed to evaluate how the 'Grip on Health' intervention is implemented in general and occupational health practice to address multi-domain problems and to promote interprofessional collaboration.

METHOD

A process evaluation was performed among 28 general and occupational health professionals, who were trained and implemented the Grip on Health intervention during a six-month period. The 'Measurement Instrument for Determinants of Innovations' was used to evaluate facilitators and barriers for implementing Grip on Health. Data included three group interviews with 17 professionals, a questionnaire and five individual interviews.

RESULTS

While most health professionals were enthusiastic about the Grip on Health intervention, its implementation was hindered by contextual factors. Barriers in the socio-political context consisted of legal rules and regulations around sickness and disability, professional protocols for interprofessional collaboration, and the Covid-19 pandemic. On the organizational level, lack of consultation time was the main barrier. Facilitators were found on the level of the intervention and the health professional. For instance, professionals described how the intervention supports addressing multi-domain problems and has created awareness of work in each other's healthcare domain. They recognized the relevance of the intervention for a broad target group and experienced benefits of its use. The intervention period was, nevertheless, too short to determine the outcomes of Grip on Health.

CONCLUSION

The Grip on Health intervention can be used to address problems on multiple life domains and to stimulate interprofessional collaboration. Visualizing multi-domain problems appeared especially helpful to guide patients with a lower socioeconomic position, and a joint training of general and occupational health professionals promoted their mutual awareness and familiarity. For a wider implementation, stakeholders on all levels, including the government and professional associations, should reflect on ways to address contextual barriers to promote a broad perspective on health as well as on collaborative work.

Equity-relevant sociodemographic variable collection in emergency medicine: A systematic review, qualitative evidence synthesis, and recommendations for practice

OBJECTIVES

The objective was to conduct a systematic review and qualitative evidence synthesis (QES) to identify best practices, benefits, harms, facilitators, and barriers to the routine collection of sociodemographic variables in emergency departments (EDs).

METHODS

This work is a systematic review and QES. We conducted a comprehensive search of Medline (Ovid), CINAHL (Ebsco), Cochrane Central (OVID), EMBASE (Ovid), and the multidisciplinary Web of Science Core database using peer-reviewed search strategies, complemented by a gray literature search. We included citations containing perspectives on routine sociodemographic variable collection in EDs and recommendations on definitions or processes of collection or benefits, harms, facilitators, or barriers related to the routine collection of sociodemographic variables in EDs. We conducted this systematic review and QES adhering to the Joanna Briggs Institute guidelines. Two reviewers independently selected included studies and extracted data. We conducted a best-fit framework synthesis and paired inductive thematic analysis of the included studies. We generated recommendations based on the QES.

RESULTS

We included 21 unique reports that enrolled 10,454 patients or respondents in our systematic review and QES. Publication dates of included studies ranged from 2011 to 2021. Included citations were published in Australia, Canada, and the United States. We synthesized 11 benefits, 14 potential harms, 15 barriers, and 19 facilitators and identified 14 best practice recommendations from included citations.

CONCLUSIONS

Health systems should routinely collect sociodemographic variables in EDs guided by recommendations that minimize harms and maximize benefits and consider relevant barriers and facilitators. Our recommendations can serve as a guide for the equity-focused reformation of emergency medicine health information systems.

Social inequalities in access to care at birth and neonatal mortality: an observational study

OBJECTIVE

To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality.

DESIGN

Retrospective analysis of a prospective cohort constituted using hospital discharge databases.

SETTING

France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital.

MAIN OUTCOME MEASURE

Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality.

RESULTS

2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584).

CONCLUSIONS

Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.

Patient views on emergency department screening and interventions related to housing

Objectives Emergency departments (EDs) serve as a health care "safety net" and may be uniquely suited to screening for and addressing patients' unmet social needs. We aimed to better understand patient perspectives on ED-based screening and interventions related to housing instability, as a step toward improving future efforts. Methods We present findings from a qualitative study using in-depth, one-on-one interviews with ED patients who had become homeless in the past 6 months. Qualitative interviewees were asked their thoughts on ED staff asking about and helping to address homelessness and housing issues. Interviews were professionally transcribed verbatim. Multiple coders identified interview text segments focused on ED-based housing screening and intervention, which were then independently analyzed thematically and discussed to reach consensus. Researchers also categorized each participant's overall opinion on ED housing screening and interventions as positive, neutral, or negative. Results Qualitative interviews were conducted with 31 patients. Four themes related to ED-based housing screening and interventions emerged: (1) patients generally welcome ED staff/providers asking about and assisting with their housing situation, with caveats around privacy and respect; (2) ED conversations about housing have potential benefits beyond addressing unmet housing needs; (3) patients may not consider the ED as a site to obtain help with housing; (4) patients' experiences navigating existing housing services can inform best approaches for the ED. Most participants expressed overall positive views of ED staff/providers asking patients about their housing situation. Conclusions Study participants generally felt positively about screening and interventions for housing in the ED. Insights from this study can inform future ED-based housing instability screening and interventions.

A Scoping Review and Narrative Synthesis Comparing the Constructs of Social Determinants of Health and Social Determinants of Mental Health: Matryoshka or Two Independent Constructs?

Background

Many health research policies invoke the construct of Social Determinants of Health, and more recently the construct of Social Determinants of Mental Health. While frequently referred to in the literature, it is unclear how these constructs relate to each other. Some commentators conceptualise the Determinants of Mental Health as a subgroup of the Determinants of general Health and others describe the Determinants of Mental Health as an autonomous construct. The current review investigates the relationship between both constructs.

Methods

Comprehensive literature searches were conducted for both constructs separately within seven electronic databases. A template analysis was conducted to compare the conceptualisations of the Social Determinants of Health and the Social Determinants of Mental Health.

Results

Of 4250 search results, 50 papers (25 for each construct) fulfilled our inclusion criteria and were incorporated into a narrative synthesis. Discussions of the Social Determinants of both general and Mental Health listed the same determinants. Both constructs were conceptualised on multiple levels and factors. Stress and health behaviour were also described as mediators for both constructs. The constructs differed, however, with respect to two components of their aetiologies and epistemologies. First, the causal mechanisms invoked for the Determinants of general Health followed predominantly direct pathways, in contrast to indirect pathways for the Social Determinants of Mental Health. Second, the Social Determinants of Mental Health were reported to influence mental health mediated through individuals' perceptions and appraisal processes. Appraisal processes were considered of far less relevance in the construct of Social Determinants of Health.

Conclusion

The constructs of Social Determinants of Health and Social Determinants of Mental Health align in many respects but differ on important aetiological and epistemological grounds. Similar social factors are considered important, but whereas physical health conditions are primarily conceptualised to be driven by objective realities, mental health is explained mainly in terms of perception of these realities. This differentiation between physical and mental health is in line with a modern understanding of mind-body-dualism, the naturalistic dualism after Chalmers. Differentiating the Social Determinants of Mental Health from the Social Determinants of Health might bear relevance for policy making and research.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

The Envirome Web Service: Patient context at the point of care

Patient context - the "envirome" - can have a significant impact on patient health. While envirome indicators are available through large scale public data sources, they are not provided in a format that can be easily accessed and interpreted at the point of care by healthcare providers with limited time during a patient encounter. We developed a clinical decision support tool to bring envirome indicators to the point of care in a large pediatric hospital system in the Kansas City region. The Envirome Web Service (EWS) securely geocodes patient addresses in real time to link their records with publicly available context data. End-users guided the design of the EWS, which presents summaries of patient context data in the electronic health record (EHR) without disrupting the provider workflow. Through surveys, focus groups, and a formal review by hospital staff, the EWS was deployed into production use, integrating publicly available data on food access with the hospital EHR. Evaluation of EWS usage during the 2020 calendar year shows that 1,034 providers viewed the EWS, with a total of 29,165 sessions. This suggests that the EWS was successfully integrated with the EHR and is highly visible. The results also indicate that 63 (6.1%) of the providers are regular users that opt to maintain the EWS in their custom workflows, logging more than 100 EWS sessions during the year. The vendor agnostic design of the EWS supports interoperability and makes it accessible to health systems with disparate EHR vendors.

Recommending encounters according to the sociodemographic characteristics of patient strata can reduce risks from type 2 diabetes

Objectives

Physician encounters with patients with type 2 diabetes act as motivation for self-management and lifestyle adjustments that are indispensable for diabetes treatment. We elucidate the sociodemographic sources of variation in encounter usage and the impact of encounter usage on glucose control, which can be used to recommend encounter usage for different sociodemographic strata of patients to reduce risks from Type 2 diabetes.

Data and methods

We analyzed data from a multi-facility clinic in the Midwestern United States on 2124 patients with type 2 diabetes, from 95 ZIP codes. A zero-inflated Poisson model was used to estimate the effects of various ZIP-code level sociodemographic variables on the encounter usage. A multinomial logistic regression model was built to estimate the effects of physical and telephonic encounters on patients’ glucose level transitions. Results from the two models were combined in marginal effect analyses.

Results and conclusions

Conditional on patients’ clinical status, demographics, and insurance status, significant inequality in patient encounters exists across ZIP codes with varying sociodemographic characteristics. One additional physical encounter in a six-month period marginally increases the probability of transition from a diabetic state to a pre-diabetic state by 4.3% and from pre-diabetic to the non-diabetic state by 3.2%. Combined marginal effect analyses illustrate that a ZIP code in the lower quartile of high school graduate percentage among all ZIP codes has 1 fewer physical encounter per six months marginally compared to a ZIP code at the upper quartile, which gives 5.4% average increase in the probability of transitioning from pre-diabetic to diabetic. Our results suggest that policymakers can target particular patient groups who may have inadequate encounters to engage in diabetes care, based on their immediate environmental sociodemographic characteristics, and design programs to increase their encounters to achieve better care outcomes.

Similarities in client-clinician perceptions of subjective social status and its association to similarities in the quality of working alliance and client anxiety symptoms

Subjective social status (SSS) has largely been ignored within psychotherapy literature. We investigated the association between similarities in client-clinician perceptions of SSS, similarities in their report of the quality of working alliance, and resultant anxiety symptoms.

Participants represented a primarily low-income, culturally diverse sample of 312 clients receiving care from 68 clinicians at 13 outpatient mental health clinics in the Northeastern United States between September 2013 and August 2016. As part of a larger randomized controlled trial, clients and clinicians completed the MacArthur Scale of subjective social status and the Working Alliance Inventory (WAI), and clients completed the Generalized Anxiety Disorder 7-item Scale (GAD-7).

At the within-clinician level, client-clinician dyads with less similar perceptions of the client's SSS were characterized by less similar perceptions of their alliance, which in turn resulted in worsening anxiety symptoms.

Clinicians' correct perception of their clients' social status might be important for sharing a similar view of the client-clinician level of alliance, which can, in turn, contribute to lowering the client's anxiety symptoms.

Socioeconomic status scales: Revised Kuppuswamy, BG Prasad, and Udai Pareekh's scale updated for 2021

Socioeconomic status (SES) is a critical measure that helps to correlate well-being and social status. SES plays a significant role in determining an individual’s quality of life, health, social position, and class. The widely accepted SES scales are the Kuppuswamy scale, BG Prasad scale, and Udai Pareekh scale. The income range is revised by using an online dedicated tool for this purpose. The scale is based on the income domain to decide the SES, which needs to be revised regularly based on the Consumer Price Index for Industrial Workers (CPI-IW). The study is the revised income range of the Kuppuswamy scale and BG Prasad scale as per the CPI-IW January 2021. However, all three scales have a few limitations and are not applicable to both the rural and urban areas at the same time.