A Population Health Impact Pyramid for Health Care.

Policy Points To meaningfully impact population health and health equity, health care organizations must take a multipronged approach that ranges from education to advocacy, recognizing that more impactful efforts are often more complex or resource intensive. Given that population health is advanced in communities and not doctors' offices, health care organizations must use their advocacy voices in service of population health policy, not just health care policy. Foundational to all population health and health equity efforts are authentic community partnerships and a commitment to demonstrating health care organizations are worthy of their communities' trust.

The Current State of Antiracism Curricula in Undergraduate and Graduate Medical Education: A Qualitative Study of US Academic Health Centers.

PURPOSE: We undertook a study to evaluate the current state of pedagogy on antiracism, including barriers to implementation and strengths of existing curricula, in undergraduate medical education (UME) and graduate medical education (GME) programs in US academic health centers. METHODS: We conducted a cross-sectional study with an exploratory qualitative approach using semistructured interviews. Participants were leaders of UME and GME programs at 5 institutions participating in the Academic Units for Primary Care Training and Enhancement program and 6 affiliated sites from November 2021 to April 2022. RESULTS: A total of 29 program leaders from the 11 academic health centers participated in this study. Three participants from 2 institutions reported the implementation of robust, intentional, and longitudinal antiracism curricula. Nine participants from 7 institutions described race and antiracism-related topics integrated into health equity curricula. Only 9 participants reported having "adequately trained" faculty. Participants mentioned individual, systemic, and structural barriers to implementing antiracism-related training in medical education such as institutional inertia and insufficient resources. Fear related to introducing an antiracism curriculum and undervaluing of this curriculum relative to other content were identified. Through learners and faculty feedback, antiracism content was evaluated and included in UME and GME curricula. Most participants identified learners as a stronger voice for transformation than faculty; antiracism content was mainly included in health equity curricula. CONCLUSIONS: Inclusion of antiracism in medical education requires intentional training, focused institutional policies, enhanced foundational awareness of the impact of racism on patients and communities, and changes at the level of institutions and accreditation bodies.

Health-Related Social Needs and Increased Readmission Rates: Findings from the Nationwide Readmissions Database.

BACKGROUND: While health-related social needs (HRSN) are known to compromise health, work to date has not clearly demonstrated the relationship between clinically acknowledged social needs, via ICD-10 Z-codes, and readmission. OBJECTIVE: Assess the rate of 30-, 60-, and 90-day readmission by the level of ICD-10-identified social need. In addition, we examined the associations between demographics, social need, hospital characteristics, and comorbidities on 30-day readmission. DESIGN: Retrospective study using the 2017 Nationwide Readmission Database PARTICIPANTS: We identified 5 domains of HRSN from ICD-10 diagnosis codes including employment, family, housing, psychosocial, and socioeconomic status (SES) and identified how many and which an individual was coded with during the year. MAIN MEASURES: The proportion of patients with 30-, 60-, and 90-day readmission stratified by the number of HRSN domains with a multivariable logistic regression to examine the relationship between the number/type of and readmission adjusting for sex, age, payer, hospital characteristics, functional limitations, and comorbidities. KEY RESULTS: From 13,217,506 patients, only 2.4% had at least one HRSN diagnosis. Among patients without HRSN, 11.5% had a 30-day readmission, compared to 27.0% of those with 1 domain, increasing to 63.5% for patients with codes in 5 domains. Similar trends were observed for 60- and 90-day readmission; 78.7% of patients with documented HRSN in all 5 domains were hospitalized again within 90 days. The adjusted odds ratio for readmission for individuals with all 5 domains was 12.55 (95% CI: 9.04, 17.43). Housing and employment emerged as two of the most commonly documented HRSN, as well as having the largest adjusted odds ratio. CONCLUSIONS: There is a dose-response relationship between the number of HRSN diagnoses and hospital readmission. This work calls attention to the need to develop interventions to reduce readmissions for those at social risk and demonstrates the significance of ICD-10 Z-codes in health outcomes studies.

Engaging With Communities - Lessons (Re)Learned From COVID-19.

Coronavirus disease 2019 (COVID-19) has underscored longstanding societal differences in the drivers of health and demonstrated the value of applying a health equity lens to engage at-risk communities, communicate with them effectively, share data, and partner with them for program implementation, dissemination, and evaluation. Examples of engagement - across diverse communities and with community organizations; tribes; state and local health departments; hospitals; and universities - highlight the opportunity to apply lessons from COVID-19 for sustained changes in how public health and its partners work collectively to prevent disease and promote health, especially with our most vulnerable communities.

Equitable Pandemic Preparedness and Rapid Response: Lessons from COVID-19 for Pandemic Health Equity.

The novel coronavirus pandemic has set in high relief the entrenched health, social, racial, political, and economic inequities within American society as the incidence of severe morbidity and mortality from the disease caused by the virus appears to be much greater in black and other racial/ethnic minority populations, within homeless and incarcerated populations, and in lower-income communities in general. The reality is that the United States is ill equipped to realize health equity in prevention and control efforts for any type of health outcome, including an infectious disease pandemic. In this article, the authors address an important question: When new waves of the current pandemic emerge, or another novel pandemic emerges, how can the United States be better prepared and also ensure a rapid response that reduces rather than exacerbates social and health inequities? The authors argue for a health equity framework to pandemic preparedness that is grounded in meaningful community engagement and that, while recognizing the fundamental causes of social and health inequity, has a clear focus on upstream and midstream preparedness and downstream rapid response efforts that put social and health equity at the forefront.

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

Importance: In recent years, hospitals and health systems have reported increasing rates of screening for patients' individual and community social needs, but few studies have explored the national landscape of screening and interventions directed at addressing health-related social needs (HRSNs) and social determinants of health (SDOH). Objective: To evaluate the associations of hospital characteristics and area-level socioeconomic indicators to quantify the presence and intensity of hospitals' screening practices, interventions, and collaborative external partnerships that seek to measure and ameliorate patients' HRSNs and SDOH. Design, Setting, and Participants: This cross-sectional study used national data from the American Hospital Association Annual Survey Database for fiscal year 2020. General-service, acute-care, nonfederal hospitals were included in the study's final sample, representing nationally diverse hospital settings. Data were analyzed from July 2022 to February 2023. Exposures: Organizational characteristics and area-level socioeconomic indicators. Main Outcomes and Measures: The outcomes of interest were hospital-reported patient screening of and strategies to address 8 HRSNs and 14 external partnership types to address SDOH. Composite scores for screening practices and external partnership types were calculated, and ordinary least-square regression analyses tested associations of organizational characteristics with outcome measures. Results: Of 2858 US hospital respondents (response rate, 67.0%), most hospitals (79.2%; 95% CI, 77.7%-80.7%) reported screening patients for at least 1 HRSN, with food insecurity or hunger needs (66.1%; 95% CI, 64.3%-67.8%) and interpersonal violence (66.4%; 95% CI, 64.7%-68.1%) being the most commonly screened social needs. Most hospitals (79.4%; 95% CI, 66.3%-69.7%) reported having strategies and programs to address patients' HRSNs; notably, most hospitals (52.8%; 95% CI, 51.0%-54.5%) had interventions for transportation barriers. Hospitals reported a mean of 4.03 (95% CI, 3.85-4.20) external partnership types to address SDOH and 5.69 (5.50-5.88) partnership types to address HRSNs, with local or state public health departments and health care practitioners outside of the health system being the most common. Hospitals with accountable care contracts (ACCs) and bundled payment programs (BPPs) reported higher screening practices (ACC: ß = 1.03; SE = 0.13; BPP: ß = 0.72; SE = 0.14), interventions (ACC: ß = 1.45; SE = 0.12; BPP: ß = 0.61; SE = 0.13), and external partnership types to address HRSNs (ACC: ß = 2.07; SE = 0.23; BPP: ß = 1.47; SE = 0.24) and SDOH (ACC: ß = 2.64; SE = 0.20; BPP: ß = 1.57; SE = 0.21). Compared with nonteaching, government-owned, and for-profit hospitals, teaching and nonprofit hospitals were also more likely to report more HRSN-directed activities. Patterns based on geographic and area-level socioeconomic indicators did not emerge. Conclusions and Relevance: This cross-sectional study found that most US hospitals were screening patients for multiple HRSNs. Active participation in value-based care, teaching hospital status, and nonprofit status were the characteristics most consistently associated with greater overall screening activities and number of related partnership types. These results support previously posited associations about which types of hospitals were leading screening uptake and reinforce understanding of the role of hospital incentives in supporting health equity efforts.

An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019.

Attention to 10th Revision of the International Classification of Disease (ICD-10)-CM Z-codes as a mechanism for capturing social risk has grown over the years. However, it remains unclear whether the use of Z-codes has changed over time. This study sought to examine the trends in Z-code use between their introduction in 2015 and the end of 2019 across 2 markedly different states. Using the Healthcare Cost and Utilization Project, all emergency department visits or hospitalizations at short-term general hospitals in Florida and Maryland from 2015 Q4 through 2019 were identified. This study focused on a subset of the Z-codes that are intended to capture social risk to identify the percentage of encounters with a Z-code, percentage of facilities using Z-codes, and facility median of number of encounters with a Z-code per 1000 encounters across quarters, states, and care settings. In total, 495,212 (0.84%) of 58,993,625 encounters had a Z-code. Despite Florida's higher area deprivation, Z-codes were less frequently used and increasing more slowly than when compared with those in Maryland. There were 2.1 times the use of Z-codes in Maryland than in Florida at the encounter level. This difference was also seen when evaluating the median number of encounters with a Z-code, per 1000 encounters (12.1 vs. 3.4). Z-codes were more commonly used at major teaching facilities, and for patients who were uninsured or on Medicaid. The use of ICD-10-CM Z-codes has increased over time, with this increase occurring at nearly all short-term general hospitals. Their use was higher in Maryland than in Florida and among major teaching facilities.

Racial and Ethnic Differences in Antiseizure Medications Among People With Epilepsy on Medicaid: A Case of Potential Inequities.

Background and Objectives: Being on a newer, second-, and third-generation antiseizure medication (ASM) may represent an important marker of quality of care for people with epilepsy. We sought to examine whether there were racial/ethnic differences in their use. Methods: Using Medicaid claims data, we identified the type and number of ASMs, as well as the adherence, for people with epilepsy over a 5-year period (2010-2014). We used multilevel logistic regression models to examine the association between newer-generation ASMs and adherence. We then examined whether there were racial/ethnic differences in ASM use in models adjusted for demographics, utilization, year, and comorbidities. Results: Among 78,534 adults with epilepsy, 17,729 were Black, and 9,376 were Hispanic. Overall, 25.6% were on older ASMs, and being solely on second-generation ASMs during the study period was associated with better adherence (adjusted odds ratio: 1.17, 95% confidence interval [CI]: 1.11-1.23). Those who saw a neurologist (3.26, 95% CI: 3.13-3.41) or who were newly diagnosed (1.29, 95% CI: 1.16-1.42) had higher odds of being on newer ASMs. Importantly, Black (0.71, 95% CI: 0.68-0.75), Hispanic (0.93, 95% CI: 0.88-0.99), and Native Hawaiian and Other Pacific Island individuals (0.77, 95% CI: 0.67-0.88) had lower odds of being on newer ASMs when compared with White individuals. Discussion: Generally, racial and ethnic minoritized people with epilepsy have lower odds of being on newer-generation ASMs. Greater adherence by people who were only on newer ASMs, their greater use among people seeing a neurologist, and the opportunity of a new diagnosis point to actionable leverage points for reducing inequities in epilepsy care.

From the national to the local: Issues of trust and a model for community-academic-engagement.

Inequities in health and health care in the United States have persisted for decades, and the impacts on equity from the COVID-19 pandemic were no exception. In addition to the disproportionate burden of the disease across various populations, the pandemic posed several challenges, which exacerbated these existing inequities. This has undoubtedly contributed to deeply rooted public mistrust in medical research and healthcare delivery, particularly among historically and structurally oppressed populations. In the summer of 2020, given the series of social injustices posed by the pandemic and highly publicized incidents of police brutality, notably the murder of George Floyd, the Association of American Medical Colleges (AAMC) enlisted the help of a national collaborative, the AAMC Collaborative for Health Equity: Act, Research, Generate Evidence (CHARGE) to establish a three-way partnership that would gather and prioritize community perspectives and lived experiences from multiple regions across the US on the role of academic medicals centers (AMCs) in advancing health and social justice. Given physical gathering constraints posed by the pandemic, virtual interviews were conducted with 30 racially and ethnically diverse community members across the country who expressed their views on how medical education, clinical care, and research could or did impact their health experiences. These interviews were framed within the context of the relationship between historically oppressed groups and the COVID-19 vaccine clinical trials underway. From the three-way partnership formed with the AAMC, AAMC CHARGE participants, and 30 community members from racially and ethnically diverse groups, qualitative methods provided lived experiences supporting other literature on the lack of trust between oppressed communities and AMCs. This led to the development of the Principles of Trustworthiness (PoT) Toolkit, which features ten principles inspired by community members' insights into how AMCs can demonstrate they are worthy of their community's trust. In the end, the three-way partnership serves as a successful model for other national medical and health organizations to establish community engaged processes that elicit and prioritize lived experiences describing relationships between AMCs and oppressed communities.

ICD-10 Z-Code Health-Related Social Needs and Increased Healthcare Utilization.

INTRODUCTION: Health-related social needs are known drivers of health and health outcomes, yet work to date to examine health-related social needs using ICD-10 Z-codes remains limited. This study seeks to evaluate the differences in the prevalence of conditions as well as utilization and cost between patients with and without health-related social needs. METHODS: Using the 2017 Florida State Emergency Department and State Inpatient Databases, this study identified patients with documented health-related social needs using ICD-10 Z-codes. The prevalence ratio was calculated for 14 conditions that are the leading causes of mortality and economic costs. In addition, ratios for the median total number of negative health events and total annual costs between patients with health-related social needs and those without health-related social needs across these conditions were calculated. Data analysis was conducted in 2021. RESULTS: Of 4,477,772 patients, 46,081 (1.0%) had documented health-related social needs and had 4 times the negative health events and 9.3 times the total annual costs. Trends of increased negative health events and costs were seen across all examined conditions; patients with health-related social needs had 2.5-3.5 times the negative health events and 2-18 times greater total costs. The biggest difference in negative health events was seen in patients with unintentional injuries and depression and psychoses (3.5 times for patients with health-related social needs), whereas the biggest difference in total costs was for unintentional injuries (18.4 times for patients with health-related social needs). CONCLUSIONS: This study shows the increased prevalence of numerous high-priority conditions as well as increased utilization and costs among patients with documented health-related social needs.

A framework for health equity in people living with epilepsy.

Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.

Evaluating the Efficacy of Medical-Legal Partnerships that Address Social Determinants of Health.

BACKGROUND: Medical-legal partnerships (MLPs) are health system-community partnerships composed of multi-disciplinary teams designed to improve patient and community health. MLPs provide legal services to address health-harming legal needs that contribute to health inequities. METHODS: A grant provided by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention established the Accelerating Health Equity, Advancing through Discovery (AHEAD) Initiative to identify, evaluate, and disseminate community-based interventions that improve health equity. Three geographically and demographically diverse institutions were chosen to strengthen the evidence-base surrounding MLP by developing standardized evaluation tools in the areas of community health, health system savings, and learner outcomes. RESULTS: The generalizable process leading to evaluation tool development is described herein, and includes the formation of multi-institutional teams, logic model development, and stakeholder interviews. CONCLUSIONS: Although MLP is presented, this process can be used by various types of community health partnerships to develop evaluation tools surrounding social determinants of health (SDOH).

Social Determinants Matter For Hospital Readmission Policy: Insights From New York City.

This study assessed the impact of individual social risk factor variables and social determinants of health (SDOH) measures on hospital readmission rates and penalties used in the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP). Using 2012-16 hospital discharge data from New York City, we projected HRRP penalties by augmenting CMS's readmission model for heart attack, heart failure, and pneumonia with SDOH scores constructed at each of four geographic levels and a measure of individual-level social risk. Including additional SDOH scores in the model, especially those constructed with the most granular geographic data, along with social risk factor variables substantially affects projected penalties for hospitals treating the highest proportion of patients with high SDOH scores. Improved performance occurred even after we included peer-group stratification in the HRRP model pursuant to the 21st Century Cures Act. Small improvements in model accuracy were associated with substantial shifts in projected performance. Our results suggest that CMS's continued omission of relevant patient and geographic data from the HRRP readmission model misallocates penalties attributable to SDOH and social risk factor effects to hospitals with the largest share of high-risk patients.

Dual eligible patients are not the same: How social risk may impact quality measurement's ability to reduce inequities.

BACKGROUND: CMS recently decided to produce private "healthcare disparities reports" that include dual eligibility (DE) as the sole stratifying variable used to assess pneumonia readmission disparities. RESEARCH DESIGN: We measure the relationship between DE status and readmissions, both with and without conceptually relevant social risk factors, including air pollution, severe housing problems, and food insecurity, using data from county- and hospital-level readmission rates, DE status, and social risk factors. RESULTS: At the county level, the relationship between DE status and readmissions is partially confounded by at least three social risk factors. DE populations vary widely across hospitals, creating unequal between-hospital comparisons. CONCLUSIONS: Because of differences in the DE population, between-hospital comparisons could be misleading using a methodology that stratifies by DE only. We suggest viable alternatives to sole-factor stratification to properly account for social risk factors and better isolate quality differences that might yield readmission rate inequities. IMPLICATIONS: CMS's healthcare disparities reports provided to hospitals are limited by relying exclusively on DE proportion as the measure of social risk, undercutting the power of quality measurement and its related incentives to close or minimize healthcare inequities.

Shifting Academic Health Centers From a Culture of Community Service to Community Engagement and Integration.

There is an increasing need for academic health centers (AHCs) to engage communities across their clinical, research, and educational missions. Although AHCs have a long-standing history of community service, a more comprehensive approach to working with communities is required to respond to shifts toward a population health paradigm, funder requirements for community engagement in research, and demands that medical education focus more on social and environmental determinants of health. Community engagement has been employed at many AHCs, though often in limited ways or relying heavily on students and faculty interested in serving communities. This limited involvement has been due, in part, to lack of infrastructure to support engagement, resource constraints, and the lack of a clear value proposition for long-term investments in community partnerships. However, there are compelling reasons for AHCs to take an enterprise-wide approach to working with communities. An enterprise-wide approach to community engagement will require reconsideration of communities, moving from viewing them as people or groups in need of service to seeing them as assets who can help AHCs better understand and address social determinants of health, enhance students' and trainees' ability to provide care, and increase the relevance and potential impact of research discoveries. To accomplish this, AHCs will need to establish the necessary infrastructure to support long-term community partnerships, adapt policies to support and reward engaged scholarship and teaching, and consider new ways of integrating community members in roles as advisors and collaborators across the AHC.

Unwinding of Continuous Medicaid Coverage Among Patients at Community Health Centers.

This retrospective cohort study uses data from the Accelerating Data Value Across a National Community Health Center Network to assess patterns of Medicaid disenrollment during the first 6 months after the end of continuous enrollment.

Changes in Teaching Hospitals' Community Benefit Spending After Implementation of the Affordable Care Act.

PURPOSE: U.S. teaching hospitals that qualify as 501(c)(3) organizations (a not-for-profit designation) are required to demonstrate community benefit annually. Increases in health insurance access driven by Affordable Care Act (ACA) implementation, along with new regulations, research opportunities, and educational expectations, may be changing hospitals' allocations of community benefit dollars. This study aimed to describe changes in teaching hospitals' community benefit spending between 2012 (pre-ACA implementation) and 2015 (post-ACA implementation), and to explore differences in spending changes between hospitals in Medicaid expansion and nonexpansion states. METHOD: In 2017, for each teaching hospital member of the Association of American Medical Colleges' (AAMC's) Council of Teaching Hospitals and Health Systems required to submit Form 990s to the Internal Revenue Service, the authors sought community benefit spending data for 2012 and 2015 as reported on Schedule H. RESULTS: The analysis included 169 pairs of Form 990s representing 184 AAMC member teaching hospitals (93% of 198 eligible hospitals). Compared with 2012, hospitals in 2015 spent $3.1 billion (20.14%) more on community benefit despite spending $804 million (16.17%) less on charity care. Hospitals in Medicaid expansion states increased spending on subsidized health services and Medicaid shortfalls at rates higher than hospitals in nonexpansion states. The latter increased spending at higher rates on community health improvement and cash/in-kind contributions. CONCLUSIONS: After ACA implementation, teaching hospitals increased their overall community benefit spending while their charity care spending declined. Changes in community benefit spending differed according to states' Medicaid expansion status, demonstrating hospitals' responsiveness to state and local realities.

Communities, Social Justice, and Academic Health Centers.

In November 2015, the Association of American Medical Colleges (AAMC) held its annual meeting in Baltimore, Maryland. In response both to health and health care inequities faced by residents of Baltimore and to the imminent trial of the police officers charged with Freddie Gray's death, AAMC leaders thought it crucial to address issues of health inequity, social injustice, and the role an academic health center (AHC) can play in improving the health of the community it serves. In collaboration with community-engaged researchers from Johns Hopkins University and University of Maryland, Baltimore, AAMC staff interviewed Baltimore residents, soliciting their perspectives on how medical education, clinical care, and research can and should respond to social injustice and the social determinants of health. The authors used the resulting videoed interviews to frame a conversation during the annual meeting aimed at developing concrete actions that an individual, an institution, or the AAMC can take to address social injustice and health inequities in the Baltimore community and beyond. The robust conversation and the action steps identified by participants led to the development of a toolkit to build the capacity of AHCs and their communities to engage in similar, action-oriented programming. The success of the conversation inspired future meeting sessions that purposefully incorporate community voices and expertise. This Perspective presents results of this action planning and places the proposed set of activities within the current health care context to demonstrate how community expertise and wisdom can inform and advance efforts to improve the health of all.

From Inputs to Impacts: Assessing and Communicating the Full Value of Biomedical Research.

Assessing and communicating the full value of biomedical research is essential to answer calls from the government and the public demanding accountability for the spending of public funds. In academic settings, however, research success is measured largely in terms of grant funding received or the number of peer-reviewed publications produced. These credible and time-tested metrics miss the full picture of the scientific process, which continues to confer benefits to patients, communities, and the health care system well after an article is published. In this context, in 2012, the Association of American Medical Colleges, in collaboration with RAND Europe, initiated a program to provide resources and guidance for leaders of medical schools and teaching hospitals interested in evaluating-in novel ways complementary to traditional methods-the outcomes and impacts of the research that emanates from their institutions. This Perspective provides context for this initiative and delineates the process through which researchers, evaluation experts, and other stakeholders-including legislators, health system leaders, and community members-identified and vetted novel "metrics that matter" in advance of a pilot test at the University of Wisconsin-Madison, which sought to assess and communicate its community-engaged science and scholarship.