Addressing Social Determinants of Health in Primary Care Patients May Reduce Hospital Readmissions: A Quasi-Experimental Study.

BACKGROUND: Health care systems are increasingly partnering with community-based organizations to address social determinants of health (SDH). We established a program that educates and connects patients with SDH needs at a primary care clinic to community services and facilitated referrals. OBJECTIVE: To evaluate the effect of addressing SDH soon after discharge on hospital readmission in a clinic population. DESIGN: Pre/post, quasi-experimental design with longitudinal data analysis for quality improvement. PARTICIPANTS: Clinic patients (n = 754) having at least one hospital discharge between June 1, 2020, and October 31, 2021, were included. Of these, 145 patients received the intervention and 609 served as comparison. INTERVENTIONS: A primary care liaison was employed to assess and educate recently discharged clinic patients for SDH needs and refer them for needed community services from June 1, 2020, to October 31, 2021. MAIN MEASURES: Hospital readmissions within 30, 60, and 90 days of discharge were tracked at 6-month intervals. Covariates included patient age, sex, race/ethnicity, insurance status, income, Hierarchical Condition Category risk scores, and Clinical Classification Software diagnosis groups. Data for all hospital discharges during the intervention period were used for the main analysis and data for the year before the intervention were extracted for comparison. KEY RESULTS: Overall, patients in the intervention group were older, sicker, and more likely to have public insurance. The reductions in 30-, 60-, and 90-day readmissions during the intervention period were 14.39%, 13.28%, and 12.04% respectively in the intervention group, while no significant change was observed in the comparison group. The group difference in reduction over time was statistically significant for 30-day (Diff = 12.54%; p = 0.032), 60-day (Diff = 14.40%; p = 0.012), and 90-day readmissions (Diff = 14.71%; p = 0.036). CONCLUSION: Our findings suggest that screening clinic patients for SDH, and educating and connecting them to community services during post-hospital care may be associated with reductions in hospital readmissions.

System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients.

Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison (PCL) model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes (PCMHs) that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3-5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes.

Malondialdehyde-acetaldehyde adducts and anti-malondialdehyde-acetaldehyde antibodies in rheumatoid arthritis.

OBJECTIVE: Malondialdehyde-acetaldehyde (MAA) adducts are a product of oxidative stress associated with tolerance loss in several disease states. This study was undertaken to investigate the presence of MAA adducts and circulating anti-MAA antibodies in patients with rheumatoid arthritis (RA). METHODS: Synovial tissue from patients with RA and patients with osteoarthritis (OA) were examined for the presence of MAA-modified and citrullinated proteins. Anti-MAA antibody isotypes were measured in RA patients (n = 1,720) and healthy controls (n = 80) by enzyme-linked immunosorbent assay. Antigen-specific anti-citrullinated protein antibodies (ACPAs) were measured in RA patients using a multiplex antigen array. Anti-MAA isotype concentrations were compared in a subset of RA patients (n = 80) and matched healthy controls (n = 80). Associations of anti-MAA antibody isotypes with disease characteristics, including ACPA positivity, were examined in all RA patients. RESULTS: Expression of MAA adducts was increased in RA synovial tissue compared to OA synovial tissue, and colocalization with citrullinated proteins was found. Increased levels of anti-MAA antibody isotypes were observed in RA patients compared to controls (P < 0.001). Among RA patients, anti-MAA antibody isotypes were associated with seropositivity for ACPAs and rheumatoid factor (P < 0.001) in addition to select measures of disease activity. Higher anti-MAA antibody concentrations were associated with a greater number of positive antigen-specific ACPA analytes (expressed at high titer) (P < 0.001) and a higher ACPA score (P < 0.001), independent of other covariates. CONCLUSION: MAA adduct formation is increased in RA and appears to result in robust antibody responses that are strongly associated with ACPAs. These results support speculation that MAA formation may be a cofactor that drives tolerance loss, resulting in the autoimmune responses characteristic of RA.