Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study.

Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.

The Construction and Meaning of Race Within Hypertension Guidelines: A Systematic Scoping Review.

BACKGROUND: Professional society guidelines are evidence-based recommendations intended to promote standardized care and improve health outcomes. Amid increased recognition of the role racism plays in shaping inequitable healthcare delivery, many researchers and practitioners have critiqued existing guidelines, particularly those that include race-based recommendations. Critiques highlight how racism influences the evidence that guidelines are based on and its interpretation. However, few have used a systematic methodology to examine race-based recommendations. This review examines hypertension guidelines, a condition affecting nearly half of all adults in the United States (US), to understand how guidelines reference and develop recommendations related to race. METHODS: A systematic scoping review of all professional guidelines on the management of essential hypertension published between 1977 and 2022 to examine the use and meaning of race categories. RESULTS: Of the 37 guidelines that met the inclusion criteria, we identified a total of 990 mentions of race categories. Black and African/African American were the predominant race categories referred to in guidelines (n = 409). Guideline authors used race in five key domains: describing the prevalence or etiology of hypertension; characterizing prior hypertension studies; describing hypertension interventions; social risk and social determinants of health; the complexity of race. Guideline authors largely used race categories as biological rather than social constructions. None of the guidelines discussed racism and the role it plays in perpetuating hypertension inequities. DISCUSSION: Hypertension guidelines largely refer to race as a distinct and natural category rather than confront the longstanding history of racism within and beyond the medical system. Normalizing race as a biological rather than social construct fails to address racism as a key determinant driving inequities in cardiovascular health. These changes are necessary to produce meaningful structural solutions that advance equity in hypertension education, research, and care delivery.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools.

BACKGROUND: Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length. OBJECTIVES: To compare two screening tools both containing questions related to financial hardship. DESIGN: Cross-sectional survey. PARTICIPANTS: Convenience sample of adult patients (n = 471) in three primary care clinics. MAIN MEASURES: Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health. RESULTS: Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01). CONCLUSIONS: Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

Revising the Logic Model Behind Health Care's Social Care Investments.

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

Associations between Social Adversity and Biomarkers of Inflammation, Stress, and Aging in Children.

BACKGROUND: Prior work has found relationships between childhood social adversity and biomarkers of stress, but knowledge gaps remain. To help address these gaps, we explored associations between social adversity and biomarkers of inflammation (interleukin-1ß [IL-1ß], IL-6, IL-8, tumor necrosis factor-alpha [TNF-α], and salivary cytokine hierarchical "clusters" based on the three interleukins), neuroendocrine function (cortisol, cortisone, dehydroepiandrosterone, testosterone, and progesterone), neuromodulation (N-arachidonoylethanolamine, stearoylethanolamine, oleoylethanolamide, and palmitoylethanolamide), and epigenetic aging (Pediatric-Buccal-Epigenetic clock). METHODS: We collected biomarker samples of children ages 0-17 recruited from an acute care pediatrics clinic and examined their associations with caregiver-endorsed education, income, social risk factors, and cumulative adversity. We calculated regression-adjusted means for each biomarker and compared associations with social factors using Wald tests. We used logistic regression to predict being in the highest cytokine cluster based on social predictors. RESULTS: Our final sample included 537 children but varied based on each biomarker. Cumulative social adversity was significantly associated with having higher levels of all inflammatory markers and with cortisol, displaying a U-shaped distribution. There were no significant relationships between cumulative social adversity and cortisone, neuromodulation biomarkers or epigenetic aging. CONCLUSION: Our findings support prior work suggesting that social stress exposures contribute to increased inflammation in children. IMPACT: Our study is one of the largest studies examining associations between childhood social adversity and biomarkers of inflammation, neuroendocrine function, neuromodulation, and epigenetic aging. It is one of the largest studies to link childhood social adversity to biomarkers of inflammation, and the first of which we are aware to link cumulative social adversity to cytokine clusters. It is also one of the largest studies to examine associations between steroids and epigenetic aging among children, and one of the only studies of which we are aware to examine associations between social adversity and endocannabinoids among children. CLINICAL TRIAL REGISTRATION: NCT02746393.

Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation.

BACKGROUND AND AIMS: Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. APPROACH AND RESULTS: We included children (age <18) listed 2005-2015 in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-list mortality (subhazard ratio [sHR], 1.44; 95% CI, 1.18, 1.75 and sHR, 1.48; 95% CI, 1.25, 1.76, respectively). After adjusting for neighborhood deprivation, insurance, and listing laboratory Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease, Black and Hispanic children did not have increased hazard of wait-list mortality (sHR, 1.12; 95% CI, 0.91, 1.39 and sHR, 1.21; 95% CI, 1.00, 1.47, respectively). Similarly, Black and Hispanic children had a decreased likelihood of LDLT (sHR, 0.58; 95% CI, 0.45, 0.75 and sHR, 0.61; 95% CI, 0.49, 0.75, respectively). Adjustment attenuated the effect of Black and Hispanic race/ethnicity on likelihood of LDLT (sHR, 0.79; 95% CI, 0.60, 1.02 and sHR, 0.89; 95% CI, 0.70, 1.11, respectively). CONCLUSIONS: Household and neighborhood socioeconomic factors and disease severity at wait-list entry help explain racial/ethnic disparities for children awaiting transplant. A nuanced understanding of how social adversity contributes to wait-list outcomes may inform strategies to improve outcomes.

Essential not Supplemental: Medicare Advantage Members' Use of Non-Emergency Medical Transportation (NEMT).

BACKGROUND: Over five million people in the USA miss or delay medical care because of a lack of transportation. Transportation barriers are especially relevant to Medicare Advantage (MA) health plan enrollees, who are more likely to live with multiple chronic conditions and experience mobility challenges. Non-Emergency Medical Transportation (NEMT) helps to address transportation gaps by providing rides to and from routine medical care (for example, medical appointments, laboratory tests, and pharmacy visits) and has been added as a supplemental benefit to some MA health plans. OBJECTIVE: We aimed to characterize MA enrollees' experiences with supplemental NEMT benefits. DESIGN: Qualitative interviews focused on participants' experiences with existing NEMT benefits, transportation, and mobility. PARTICIPANTS: Twenty-one MA enrollees who used their MA NEMT benefit in 2019 and who remained eligible for ongoing transportation benefits through 2021. APPROACH: Using purposive sampling from a list of eligible participants, we recruited individuals who used their MA NEMT benefit in 2019 and who remained eligible for benefit-covered transportation services through 2021. KEY RESULTS: Participants considered NEMT an essential service, particularly because these services helped them decrease social isolation, reduce financial insecurity, and manage their own medical needs. Navigating logistical challenges associated with arranging NEMT services required participants to commit considerable time and energy and limited the effectiveness and reliability of NEMT. CONCLUSION: Participants described NEMT as a valued service essential to their ability to access health care. They suggested ways to increase service flexibility and reliability that could inform future NEMT policy and practice. As health systems and payers learn how to best address social risks, particularly as the US population ages, our findings underscore the importance of NEMT services and highlight opportunities to advance comprehensive transportation solutions for MA participants.

Community Health Center Staff Perspectives on Financial Payments for Social Care.

Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee-for-service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee-for-service payments are unlikely to strongly influence CHC social care practices. CONTEXT: A growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients' social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities. METHODS: We interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches. FINDINGS: We grouped findings into three categories: participants' awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well. CONCLUSIONS: Small fee-for-service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives-e.g., by increasing clinical teams' awareness of incentives, linking screening to well-funded social services, and changing incentive amounts to support social care staffing needs-may increase the uptake of social care practices in CHCs.

Patient-Reported Social Risks and Clinician Decision Making: Results of a Clinician Survey in Primary Care Community Health Centers.

PURPOSE: To assess the extent that patients' social determinants of health (SDOH) influence safety-net primary care clinicians' decisions at the point of care; examine how that information comes to the clinician's attention; and analyze clinician, patient, and encounter characteristics associated with the use of SDOH data in clinical decision making. METHODS: Thirty-eight clinicians working in 21 clinics were prompted to complete 2 short card surveys embedded in the electronic health record (EHR) daily for 3 weeks. Survey data were matched with clinician-, encounter-, and patient-level variables from the EHR. Descriptive statistics and generalized estimating equation models were used to assess relationships between the variables and the clinician reported use of SDOH data to inform care. RESULTS: Social determinants of health were reported to influence care in 35% of surveyed encounters. The most common sources of information on patients' SDOH were conversations with patients (76%), prior knowledge (64%), and the EHR (46%). Social determinants of health were significantly more likely to influence care among male and non-English-speaking patients, and those with discrete SDOH screening data documented in the EHR. CONCLUSIONS: Electronic health records present an opportunity to support clinicians integrating information about patients' social and economic circumstances into care planning. Study findings suggest that SDOH information from standardized screening documented in the EHR, combined with patient-clinician conversations, may enable social risk-adjusted care. Electronic health record tools and clinic workflows could be used to support both documentation and conversations. Study results also identified factors that may cue clinicians to include SDOH information in point-of-care decision-making. Future research should explore this topic further.

Social Risk Factor Documentation in Emergency Departments.

STUDY OBJECTIVE: Social Z codes are International Classification of Diseases, Tenth Revision, Clinical Modification codes that provide one way of documenting social risk factors in electronic health records. Despite the utility and availability of these codes, no study has examined social Z code documentation prevalence in emergency department (ED) settings. METHODS: In this descriptive, cross-sectional study of all ED visits included in the 2018 Nationwide Emergency Department Sample, we estimated the prevalence of social Z code documentation and used logistic regression to examine the association between documentation and patient and hospital characteristics. RESULTS: Of more than 35.8 million adult and pediatric ED visits, there was a 1.21% weighted prevalence (n=452,499) of at least 1 documented social Z code. Social Z codes were significantly more likely to be documented in ED visits among patients aged 35 to 64 compared to patients aged 18 to 34 (18.6/1000 [16.9 to 20.4] versus 12.7/1000 [11.5 to 14.0], odds ratio (OR) 1.47 [1.42 to 1.53]), male patients (16.6/1000 [15.1 to 18.2] versus female 8.5/1000 [7.8 to 9.2], OR 1.97 [1.89 to 2.06]), patients with Medicaid compared to patients with private insurance (15.9/1000 [14.4 to 17.6] versus (6.6/1000 [6.0 to 7.2], OR 2.45 [1.30 to 1.63]), and patients who had a Charlson Comorbidity Index≥1 compared to those with a Charlson Comorbidity Index of 0 (ranges 15.0 to 16.6/1000 versus 10.6/1000 [9.6 to 11.7], ORs ranging 1.43 to 1.58). ED visits with a primary diagnosis of mental, behavioral, and neurodevelopmental illness had the strongest positive association with social Z code documentation (85.6/1000 [78.4 to 93.4], OR 10.75 [9.88 to 11.70]) compared to ED visits without this primary diagnosis. CONCLUSION: We found a very low prevalence of social Z code documentation in ED visits nationwide. More systematic social Z code documentation could support targeted social interventions, social risk payment adjustments, and future policy reforms.

Stakeholder perspectives on social screening in US healthcare settings.

BACKGROUND: Evidence on the health impacts of social conditions has led US healthcare systems to consider identifying and addressing social adversity-e.g. food, housing, and transportation insecurity-in care delivery settings. Social screening is one strategy being used to gather patient information about social circumstances at the point of care. While several recent studies describe the rapid proliferation of social screening activities, little work has explored either why or how to implement social screening in clinical settings. Our study objectives were to assess diverse healthcare stakeholder perspectives on both the rationale for social screening and evidence needed to inform practice and policy-relevant implementation decisions. METHODS: We convened five focus groups with US experts representing different stakeholder groups: patient advocates, community-based organizations, healthcare professionals, payers, and policymakers. In total, 39 experts participated in approximately 90-minute long focus groups conducted between January-March 2021. A inductive thematic analysis approach was used to analyze discussions. RESULTS: Three themes emerged from focus groups, each reflecting the tension between the national enthusiasm for screening and existing evidence on the effectiveness and implementation of screening in clinical settings: (1) ambiguity about the rationale for social screening; (2) concerns about the relavence of screening tools and approaches, particularly for historically marginalized populations; (3) lack of clarity around the resources needed for implementation and scaling. CONCLUSION: While participants across groups described potential benefits of social screening, they also highlighted knowledge gaps that interfered with realizing these benefits. Efforts to minimize and ideally resolve these knowledge gaps will advance future social screening practice and policy.

What to Do When Everything Happens at Once: Analytic Approaches to Estimate the Health Effects of Co-Occurring Social Policies.

Social policies have great potential to improve population health and reduce health disparities. Increasingly, those doing empirical research have sought to quantify the health effects of social policies by exploiting variation in the timing of policy changes across places. Multiple social policies are often adopted simultaneously or in close succession in the same locations, creating co-occurrence that must be handled analytically for valid inferences. Although this is a substantial methodological challenge for researchers aiming to isolate social policy effects, only in a limited number of studies have researchers systematically considered analytic solutions within a causal framework or assessed whether these solutions are being adopted. We designated 7 analytic solutions to policy co-occurrence, including efforts to disentangle individual policy effects and efforts to estimate the combined effects of co-occurring policies. We used an existing systematic review of social policies and health to evaluate how often policy co-occurrence is identified as a threat to validity and how often each analytic solution is applied in practice. Of the 55 studies, only in 17 (31%) did authors report checking for any co-occurring policies, although in 36 studies (67%), at least 1 approach was used that helps address policy co-occurrence. The most common approaches were adjusting for measures of co-occurring policies; defining the outcome on subpopulations likely to be affected by the policy of interest (but not other co-occurring policies); and selecting a less-correlated measure of policy exposure. As health research increasingly focuses on policy changes, we must systematically assess policy co-occurrence and apply analytic solutions to strengthen studies on the health effects of social policies.

Addressing Social Adversity to Improve Outcomes for Children After Liver Transplant.

The social determinants of health, defined as the conditions in which we live, learn, work, and play, undoubtedly impact health outcomes. Social adversity in childhood perpetuates over the life course and has consequences extending into adulthood. This link between social adversity and adverse outcomes extends to children undergoing liver transplant, with children from socioeconomically deprived neighborhoods experiencing a greater burden of morbidity and mortality after transplant. Yet, we lack an in-depth understanding of how to address social adversity for these children. Herein, we lay out a strategy to develop and test interventions to address social adversity for children undergoing liver transplant. To do so, we believe that more granular data on how specific social risk factors (e.g., food insecurity) impact outcomes for children after liver transplant are needed. This will provide the liver transplant community with knowledge on the most pressing problems. Then, using the National Academies of Sciences, Engineering, and Medicine's framework for integrating social needs into medical care, the health system can start to develop and test health system interventions. We believe that attending to our patients' social adversity will realize improved outcomes for children undergoing liver transplant.

Financing Approaches to Social Prescribing Programs in England and the United States.

Policy Points The number of social prescribing practices, which aim to link patients with nonmedical services and supports to address patients' social needs, is increasing in both England and the United States. Traditional health care financing mechanisms were not designed to support social prescribing practices, and flexible payment approaches may not support their widespread adoption. Policymakers in both countries are shifting toward developing explicit financing streams for social prescribing programs. Consequently, we need an evaluation of them to assess their success in supporting both the acceptance of these programs and their impacts. Investment in community-based organizations and wider public services will likely be crucial to both the long-term effectiveness and the sustainability of social prescribing.

Social Care Recommendations in National Diabetes Treatment Guidelines.

PURPOSE OF REVIEW: An expanding body of research documents associations between socioeconomic circumstances and health outcomes, which has led health care institutions to invest in new activities to identify and address patients' social circumstances in the context of care delivery. Despite growing national investment in these "social care" initiatives, the extent to which social care activities are routinely incorporated into care for patients with type II diabetes mellitus (T2D), specifically, is unknown. We conducted a scoping review of existing T2D treatment and management guidelines to explore whether and how these guidelines incorporate recommendations that reflect social care practice categories. RECENT FINDINGS: We applied search terms to locate all T2D treatment and management guidelines for adults published in the US from 1977 to 2021. The search captured 158 national guidelines. We subsequently applied the National Academies of Science, Engineering, and Medicine framework to search each guideline for recommendations related to five social care activities: Awareness, Adjustment, Assistance, Advocacy, and Alignment. The majority of guidelines (122; 77%) did not recommend any social care activities. The remainder (36; 23%) referred to one or more social care activities. In the guidelines that referred to at least one type of social care activity, adjustments to medical treatment based on social risk were most common [34/36 (94%)]. Recommended adjustments included decreasing medication costs to accommodate financial strain, changing literacy level or language of handouts, and providing virtual visits to accommodate transportation insecurity. Ensuring that practice guidelines more consistently reflect social care best practices may improve outcomes for patients living with T2D.

Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System.

PURPOSE: Because social conditions such as food insecurity and housing instability shape health outcomes, health systems are increasingly screening for and addressing patients' social risks. This study documented the prevalence of social risks and examined the desire for assistance in addressing those risks in a US-based integrated delivery system. METHODS: A survey was administered to Kaiser Permanente members on subsidized exchange health insurance plans (2018-2019). The survey included questions about 4 domains of social risks, desire for help, and attitudes. We conducted a descriptive analysis and estimated multivariate modified Poisson regression models. RESULTS: Of 438 participants, 212 (48%) reported at least 1 social risk factor. Housing instability was the most common (70%) factor reported. Members with social risks reported more discomfort being screened for social risks (14.2% vs 5.4%; P = .002) than those without risks, although 90% of participants believed that health systems should assist in addressing social risks. Among those with 1-2 social risks, however, only 27% desired assistance. Non-Hispanic Black participants who reported a social risk were more than twice as likely to desire assistance compared with non-Hispanic White participants (adjusted relative risk [RR] 2.2; 95% CI, 1.3-3.8). CONCLUSIONS: Athough most survey participants believed health systems have a role in addressing social risks, a minority of those reporting a risk wanted assistance and reported more discomfort being screened for risk factors than those without risks. Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.VISUAL ABSTRACT.

Social risks and social needs in a health insurance exchange sample: a longitudinal evaluation of utilization.

BACKGROUND: Health systems are increasingly attempting to intervene on social adversity as a strategy to improve health care outcomes. To inform health system efforts to screen for social adversity, we sought to explore the stability of social risk and interest in assistance over time and to evaluate whether the social risk was associated with subsequent healthcare utilization. METHODS: We surveyed Kaiser Permanente members receiving subsidies from the healthcare exchange in Southern California to assess their social risk and desire for assistance using the Accountable Health Communities instrument. A subset of initial respondents was randomized to be re-surveyed at either three or six months later. RESULTS: A total of 228 participants completed the survey at both time points. Social risks were moderate to strongly stable across three and six months (Kappa range = .59-.89); however, social adversity profiles that included participants' desire for assistance were more labile (3-month Kappa = .52; 95% CI = .41-.64 & 6-month Kappa = .48; 95% CI = .36-.6). Only housing-related social risks were associated with an increase in acute care (emergency, urgent care) six months after initial screening; no other associations between social risk and utilization were observed. CONCLUSIONS: This study suggests that screening for social risk may be appropriate at intervals of six months, or perhaps longer, but that assessing desire for assistance may need to occur more frequently. Housing risks were associated with increases in acute care. Health systems may need to engage in screening and referral to resources to improve overall care and ultimately patient total health.

Center variation in long-term outcomes for socioeconomically deprived children.

Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.

How Hypertension Guidelines Address Social Determinants of Health: A Systematic Scoping Review.

BACKGROUND: Patient-level and community-level social and economic conditions impact hypertension risk and control. We examined adult hypertension management guidelines to explore whether and how existing guidelines refer to social care activities. OBJECTIVE: The objective of this study was to explore how hypertension guidelines reference social care activities. RESEARCH DESIGN: A systematic scoping review of clinical guidelines for adult hypertension management. We employed a PubMed search strategy to identify all hypertension guidelines published in the United States between 1977 and 2019. We reviewed all titles to identify the most updated versions focused on nonpregnant adults with hypertension. We extracted instances where guidelines referred to social determinants of health (SDH) or social care activities. The primary outcome was how guidelines covered social care activities, defined using a framework adapted from the National Academies of Sciences, Engineering, and Medicine (NASEM). RESULTS: Search terms yielded 126 guidelines. Thirty-six guidelines met the inclusion criteria. Of those, 72% (26/36) recommended social care activities as part of hypertension management; 58% recommended clinicians change clinical practice based on social risk information. These recommendations often lacked specific guidance around how to directly address social risk factors or reduce the impact of these risks on hypertension management. When guidelines referred to specific social factors, patient financial security was the most common. Over time, hypertension guidelines have included more references to SDH. CONCLUSION: Information about SDH is included in many hypertension guidelines, but few guidelines provide clear guidance for clinicians or health systems on how to identify and address social risk factors in the context of care delivery.