Social Determinants of Health: What Are They and How Do We Screen

Physician Documentation of Social Determinants of Health: Results from Two National Surveys

OBJECTIVE

We measured physicians' (1) perceived importance of having access to social determinants of health (SDOH) data received from external providers in the electronic health record (EHR); (2) internal SDOH documentation practices in the EHR, including whether physicians document SDOH in a structured format that may facilitate use; and (3) use of EHR SDOH data to identify community resources and make referrals on behalf of patients.

APPROACH

We conducted a secondary analysis of two national physician surveys.

PARTICIPANTS

Respondents from the American Board of Family Medicine Recertification Survey (ABFM, n = 4040), a survey of family physicians fielded 2021-2022, and the National Physician Health IT Survey (NPHIT, n = 3006), a survey of outpatient physicians across specialty areas fielded in 2022.

KEY RESULTS

Under half of physicians felt that SDOH data were very important (ABFM: 44.8%, NPHIT: 30.8%). Although most physicians documented SDOH in the EHR (ABFM: 72%, NPHIT: 63.3%), fewer used structured documentation methods (ABFM: 56.3%, NPHIT: 33.2%). In both surveys, physicians who participated in value-based care initiatives, those for whom > 10% of their patient population was considered vulnerable, and those who felt that their clinic had the resources to address patients' social needs had higher likelihood of documenting SDOH. Sixty-two percent of family physicians reported using SDOH data for identifying resources and making referrals.

CONCLUSIONS

In 2022, most physicians documented SDOH data in their EHR, yet fewer used structured methods, limiting data exchange opportunities to address patients' social needs. Under half of physicians considered access to external SDOH data to be "very" important, suggesting greater reliance on data collected internally and missed opportunities to identify patients who need support. Variation in perceived importance of SDOH data access and SDOH documentation by physician characteristics indicate opportunities to support adoption of structured documentation tools facilitating SDOH data capture and exchange to improve patient-centered care.

Development of a statewide network hub for screening, referral, and enrollment into food as medicine programs across Kentucky

Widespread recognition of food as medicine interventions' role in reducing food insecurity and improving health outcomes has recently emerged. Several states have released In Lieu of Services, state-approved alternative services that may be offered by managed care organizations in place of covered benefits, or 1,115 Medicaid waivers, which may allow for expanded nutrition services to reduce food insecurity and improve health outcomes. However, there are significant gaps in understanding how to create a statewide system for delivering "healthcare by food" interventions. The University of Kentucky Food as Health Alliance first piloted the development of a statewide hub facilitating referral to, enrollment in, and evaluation of food as medicine programs across two healthcare providers (one urban and one rural). We then used a quasi experimental study design to examine effects on systolic and diastolic blood pressure in a target population of Medicaid eligible individuals aged 18-64 with high blood pressure and/or type 2 diabetes in rural and urban areas. Participant allocation was based on geographic location for each program arm with no control group. This feasibility case study aims to: (1) outline the development of a referral system between healthcare and food as medicine providers; (2) describe gaps in referral and enrollment; (3) summarize lessons learned from a statewide network as a blueprint for other states; and (4) present clinical outcomes across three food as medicine programs. Ninety-two referrals were received from UK HealthCare with 21 enrolled in medically tailored meals and 28 enrolled in a grocery prescription (53% enrollment rate). Thirty-two referrals were received from Appalachian Regional Healthcare with 26 enrolled in meal kits (81% enrollment rate). On average, the reduction in systolic blood pressure was 9.67 mmHg among medically tailored meals participants and 6.89 mmHg among grocery prescription participants. Creating a statewide system to address food insecurity and clinical outcomes requires key support from a host of stakeholders. Policy steps moving forward need to consider funding and infrastructure for screening, referral, enrollment and engagement hubs for improved health outcomes.

Clinical trial registration

ClinicalTrials.gov, NCT06033664.

Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events

PURPOSE

To use machine learning to examine health equity and clinical outcomes in patients who experienced a nurse sensitive indicator (NSI) event, defined as a fall, a hospital-acquired pressure injury (HAPI) or a hospital-acquired infection (HAI).

DESIGN

This was a retrospective observational study from a single academic hospital over six calendar years (2016-2021). Machine learning was used to examine patients with an NSI compared to those without.

METHODS

Inclusion criteria: all adult inpatient admissions (2016-2021). Three approaches were used to analyze the NSI group compared to the No-NSI group. In the univariate analysis, descriptive statistics, and absolute standardized differences (ASDs) were employed to compare the demographics and clinical variables of patients who experienced a NSI and those who did not experience any NSIs. For the multivariate analysis, a light grading boosting machine (LightGBM) model was utilized to comprehensively examine the relationships associated with the development of an NSI. Lastly, a simulation study was conducted to quantify the strength of associations obtained from the machine learning model.

RESULTS

From 163,507 admissions, 4643 (2.8%) were associated with at least one NSI. The mean, standard deviation (SD) age was 59.5 (18.2) years, males comprised 82,397 (50.4%). Non-Hispanic White 84,760 (51.8%), non-Hispanic Black 8703 (5.3%), non-Hispanic Asian 23,368 (14.3%), non-Hispanic Other 14,284 (8.7%), and Hispanic 30,271 (18.5%). Race and ethnicity alone were not associated with occurrence of an NSI. The NSI group had a statistically significant longer length of stay (LOS), longer intensive care unit (ICU) LOS, and was more likely to have an emergency admission compared to the group without an NSI. The simulation study results demonstrated that likelihood of NSI was higher in patients admitted under the major diagnostic categories (MDC) associated with circulatory, digestive, kidney/urinary tract, nervous, and infectious and parasitic disease diagnoses.

CONCLUSION

In this study, race/ethnicity was not associated with the risk of an NSI event. The risk of an NSI event was associated with emergency admission, longer LOS, longer ICU-LOS and certain MDCs (circulatory, digestive, kidney/urinary, nervous, infectious, and parasitic diagnoses).

CLINICAL RELEVANCE

Machine learning methodologies provide a new mechanism to investigate NSI events through the lens of health equity/disparity. Understanding which patients are at higher risk for adverse outcomes can help hospitals improve nursing care and prevent NSI injury and harm.

Influence of Patient Gender on In-Hospital Mortality: A Population-Based Cross-Sectional Study

AIM

To analyse the association between gender and in-hospital mortality odds ratios among patients in the Basque Country.

DESIGN

Cross-sectional study.

METHODS

Admission data pertaining to the period between 1 January 2016 and 31 December 2018 were gathered for all registered acute care hospitals (both public and private) in the Basque Country. Odds ratios were calculated through binomial logistic regressions to determine the association between gender and mortality in each diagnostic category of the ICD-10.

RESULTS

Women had a higher in-hospital mortality odds ratio for diseases of the circulatory system (OR 1.07 [1.01-1.14], p < 0.05). In contrast, men were at greater risk of in-hospital death from neoplasms (OR 0.86 [0.83-0.94], p < 0.05), diseases of the nervous system (OR 0.83 [0.70-0.97], p < 0.05), diseases of the genitourinary system (OR 0.83 [0.71-0.96], p < 0.05), endocrine diseases (OR 0.67 [0.54-0.84], p < 0.05), injury, poisoning and other consequences of external causes (OR 0.60 [0.54-0.67], p < 0.05) and diseases of the musculoskeletal system and connective tissue (OR 0.69 [0.50-0.93], p < 0.05).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contributions.

People Living With Mental Illness Perceptions of Physical Health, Mental Health and Well-Being

Understanding the perspectives of regional people living with mental illness is crucial to adapting services, improving holistic care and meeting individual needs. This study explored people living with mental illness perceptions of physical health, mental health and well-being. A descriptive qualitative study design underpinned by empowerment theory was conducted. Qualitative data were collected verbally via semi-structured interviews, with demographic details provided verbally at the end of the interview. Thematic analysis was utilised to identify themes. The COREQ checklist was used for reporting. Fourteen participants admitted to regional mental health inpatient units aged between 25 and 84 years old were interviewed. Participants felt their overall well-being was good despite feeling their physical health or mental health was suboptimal, suggesting that their perceived well-being is influenced by factors beyond their physical and mental health. Most participants reported looking after their physical health, mental health and well-being and identified various behavioural lifestyle strategies they found helpful. Thematic analysis identified three themes: functioning well, feeling in control and meeting basic needs. Mental health services and clinicians play an important role in empowering people with mental illness to improve their physical health, mental health and well-being while admitted to inpatient services; however, it is acknowledged resources can be limited. Mental health services may consider referring people with mental illness to social prescribing programmes to meet their individualised needs on discharge.

Volunteerism Addressing Environmental Disparities in Allergy (VAEDIA): The presidential initiative to combat environmental injustice in allergy and immunology-a Work Group Report of the AAAAI VAEDIA task force

Many vulnerable people lose their health or lives each year as a result of unhealthy environmental conditions that perpetuate medical conditions within the scope of allergy and immunology specialists' expertise. While detrimental environmental factors impact all humans globally, the effect is disproportionately more profound in impoverished neighborhoods. Environmental injustice is the inequitable exposure of disadvantaged populations to environmental hazards. Professional medical organizations such as the American Academy of Allergy, Asthma & Immunology (AAAAI) are well positioned to engage and encourage community outreach volunteer programs to combat environmental justice. Here we discuss how environmental injustices and climate change impacts allergic diseases among vulnerable populations. We discuss pathways allergists/immunologists can use to contribute to addressing environmental determinants by providing volunteer clinical service, education, and advocacy. Furthermore, allergists/immunologists can play a role in building trust within these communities, partnering with other patient advocacy nonprofit stakeholders, and engaging with local, state, national, and international nongovernmental organizations, faith-based organizations, and governments. The AAAAI's Volunteerism Addressing Environmental Disparities in Allergy (VAEDIA) is the presidential task force aiming to promote volunteer initiatives by creating platforms for discussion and collaboration and by funding community-based projects to address environmental injustice.

Nursing Students' Perception of Caring for Culturally Diverse Patients: A Hermeneutic Phenomenological Study

BACKGROUND

This study examined the phenomenon of prelicensure nursing students caring for culturally diverse patients.

METHOD

Individual interviews were conducted with undergraduate nursing students using a hermeneutic phenomenological approach. Qualitative research experts conducted the interviews, transcribed the data, and followed van Manen's methodology for analysis.

RESULTS

Eleven nursing students participated in the study. Data were collected from April to August 2022. The average length of the student interviews was 32 minutes. Four themes were identified: (1) communication issues; (2) access to care; (3) nurse background; and (4) trust and respect.

CONCLUSION

This study highlights the importance of caring for culturally diverse patients. Policymakers and health care leaders can use the findings to support legislative proposals for enhancing culturally diverse patient safety and health equity. Based on these findings, nurse educators and preceptors can adapt their clinical teaching approaches accordingly, and nurse managers can benefit from the results when hiring new graduate nurses. [J Nurs Educ. 2024;63(6):373-379.].

Nurse informaticists' role in promoting health equity

ABSTRACT

Nurse informaticists (NIs) play a pivotal role in addressing health-related social needs through integrating technology into electronic health records. NIs navigate regulatory landscapes, emphasizing screening for social determinants of health during hospital encounters. This article underscores NIs' strategic contributions to optimizing data collection, supporting health equity, and utilizing innovative technologies to bridge gaps in healthcare outcomes.

Screening tools to address social determinants of health in the United States: A systematic review

The Centers for Medicare & Medicaid Services have mandated that hospitals implement measures to screen social determinants of health (SDoH). We sought to report on available SDoH screening tools. PubMed, Scopus, Web of Science, as well as the grey literature were searched (1980 to November 2023). The included studies were US-based, written in English, and examined a screening tool to assess SDoH. Thirty studies were included in the analytic cohort. The number of questions in any given SDoH assessment tool varied considerably and ranged from 5 to 50 (mean: 16.6). A total of 19 SDoH domains were examined. Housing (n = 23, 92%) and safety/violence (n = 21, 84%) were the domains assessed most frequently. Food/nutrition (n = 17, 68%), income/financial (n = 16, 64%), transportation (n = 15, 60%), family/social support (n = 14, 56%), utilities (n = 13, 52%), and education/literacy (n = 13, 52%) were also commonly included domains in most screening tools. Eighteen studies proposed specific interventions to address SDoH. SDoH screening tools are critical to identify various social needs and vulnerabilities to help develop interventions to address patient needs. Moreover, there is marked heterogeneity of SDoH screening tools, as well as the significant variability in the SDoH domains assessed by currently available screening tools.

Orthopaedic Sports Medicine Randomized Controlled Trials Infrequently Report on the Social Determinants of Health Factors of Their Patient Cohorts

PURPOSE

To describe the prevalence of randomized controlled trials (RCTs) in orthopaedic sports medicine-related journals reporting on the social determinants of health (SDOH) of their patient cohorts, including factors receiving less attention, such as education level, employment status, insurance status, and socioeconomic status.

METHODS

The PubMed/MEDLINE database was used to search for RCTs between 2020 and 2022 from 3 high-impact orthopaedic sports medicine-related journals: American Journal of Sports Medicine, Arthroscopy, and Journal of Shoulder and Elbow Surgery. The following information was extracted from each article: age, sex/gender, body mass index, year published, corresponding author country, and self-reported SDOH factors (race, ethnicity, education level, employment status, insurance status, and socioeconomic status).

RESULTS

A total of 189 articles were analyzed. Articles originated from 34 different countries, with the United States (n = 66) producing the greatest number of articles. Overall, age (n = 186; 98.4%) and sex/gender (n = 184; 97.4%) were the factors most commonly reported, followed by body mass index (n = 112; 59.3%), race (n = 17; 9.0%), ethnicity (n = 10; 5.3%), employment status (n = 9; 4.8%), insurance status (n = 7; 3.7%), and education level (n = 5; 2.6%). Socioeconomic status was not reported in any of the articles analyzed. Articles from the United States report on SDOH factors more frequently than international articles, most notably race (24.2% vs 0.8%, respectively) and ethnicity (15.2% and 0%, respectively).

CONCLUSIONS

RCTs from 3 high-impact orthopaedic sports medicine journals infrequently report on SDOH.

CLINICAL RELEVANCE

Better understanding patient SDOH factors in RCTs is important to help orthopaedic surgeons and other practitioners best apply study results to their patients, as well as help researchers and our field ensure that research is being done transparently with relevance to as many patients as possible.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

The impact of patients' social backgrounds assessment on nursing care: Qualitative research

Background

Although nurses are expected to address the social determinants of health (SDH) in clinical settings, the perspectives of front-line nurses on the integration of SDH into their clinical practice remain unclear. Understanding the dynamism of this integration and its outcomes can yield crucial insights into effective nursing care. This study aims to elucidate the integration and adoption of tool-based SDH assessment nursing programs and their impacts on daily nursing care.

Methods

We conducted qualitative research at a small community-based hospital in Japan, where a tool-based program characterized by social background interviews and documentation was implemented. Nurses at the hospital were recruited via purposive and snowball sampling. After hypothesis generation, semi-constructed in-depth online interviews were conducted. Each interview lasted between 30 and 50 min. The data were analyzed via thematic analysis using the framework approach.

Results

A total of 16 nurses participated. Participants' incorporation of the novel SDH assessment program was bolstered by prior learning and their recognition of its practical value. Institutional support and collaborative teamwork further facilitated the adoption of this innovation. Enhanced knowledge about the social contexts of their patients contributed to increased respect, empathy, and self-affirmation among participants, consequently enhancing the quality of nursing care.

Conclusion

Through team-based learning, reflection, and support, nurses can integrate a tool-based SDH assessment program into their daily nursing practice. This program has the potential to empower nurses to deliver more holistic care and redefine their professional identity. Further research is warranted to assess patient-reported outcomes.

A systematic review of reviews on the psychometric properties of measures of older persons' ability to build and maintain social relationships

BACKGROUND

Within the scope of the World Health Organisation's (WHO) world report on ageing and health and how healthy ageing was conceptualised, the WHO has been working with academia towards producing reviews of the psychometric properties of instruments that measure different domains of functional ability. This study aimed to conduct a review of reviews to examine existing and validated instruments measuring the ability of older persons to build and maintain social relationships and to evaluate the psychometric properties of these instruments.

METHODS

We searched for studies published in the English, Spanish and Portuguese languages. No restrictions were placed on the year of publication. The following databases were searched: PubMed, Embase, Psyinfo and Cumulated Index to Nursing and Allied Health Literature. Titles and abstracts were screened and selected articles were screened and reviewed independently by two reviewers.

RESULTS

A total of 3,879 records were retrieved, of which 39 records were retrieved for full-text analysis. None of the reviews met the inclusion criteria, thus resulting in an empty review.

CONCLUSIONS

Considering the current definition of older persons' functional ability to build and maintain social relationships, this review did not identify instruments that can measure both constructs simultaneously. We suggest the development of an instrument that simultaneously assesses the ability of older persons to build and maintain relationships.

Screening for Social Determinants of Health in Transitional Care Patients and Partnering With the Faith Community to Address Food Insecurity

PURPOSE/OBJECTIVES

The purposes of this project were to collect and document social determinants of health (SDOH) data, and to partner with the faith community to address identified food insecurity.

PRIMARY PRACTICE SETTING

The setting for this project was an ambulatory care clinic in Guilford County, North Carolina. The clinic offers care to patients discharged from a regional medical center who have no insurance and/or primary care providers.

FINDINGS/CONCLUSIONS

Clinic staff successfully developed and implemented a screening tool for entering SDOH data into the electronic health record (EHR) charts of clinic patients. Results demonstrated that 52% of clinic patients reported food insecurity. The clinic collaborated with the faith community to provide donated food bags to patients in need.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

SDOH data were largely absent from the EHR before the clinic case manager started this project. Results of the screening tool demonstrated higher rates of food insecurity than expected. The case manager worked with the faith community to address immediate needs of food insecurity. The case manager plans to share SDOH information with the wider community to affect positive change and to encourage other clinics and departments to start collecting SDOH data.

Longitudinal disparities in social determinants of health and COVID-19 incidence and mortality in the United States from the three largest waves of the pandemic

The United States experienced at least five COVID-19 waves linked with different mutated SARS-CoV-2 variants including Alpha, Delta and Omicron. In addition to the variants, the intensity, geographical distribution, and risk factors related to those waves also vary within socio-demographic characteristics and timeframes. In this project, we have examined the spatial and temporal pattern of COVID-19 in the USA and its associations with Social Determinants of Health (SDoH) by utilizing the County Health Rankings & Roadmaps (CHRR) dataset. Our epidemiologic investigation at the county level showed that the burden of COVID-19 cases and deaths is higher in counties with high percentages of smoking, number of preventable hospital stays, primary care physician rate, the average daily density of PM_2.5 and percentages of high proportions of Hispanic residents. In addition, the analysis also demonstrated that COVID-19 incidence and mortality had distinct characteristics in their association with SDoH variables. For example, the percentages of the population 65 and older had negative associations with incidence while a significant positive association with mortality. In addition to the elderly population, median household income, unemployment, and number of drug overdose deaths showed a mixed association with COVID-19 incidence and mortality. Our findings validate several influential factors found in the existing social epidemiology literature and highlight temporal associations between SDoH variables and COVID-19 incidence and mortality not yet frequently studied.