Relationship between Unstable Housing, Food Insecurity, and Vision Status in the MI-SIGHT Community Eye Disease Screening Program.

PURPOSE: Assess rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical shop. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA] ≤ 20/50, best corrected visual acuity [BCVA] ≥ 20/40), URE without VI (PVA ≥ 20/40, had ≥ 2 lines of improvement to BCVA), and no or adequately corrected RE (PVA ≥ 20/40, < 2 line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared between groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, the average age was 55.1 years (standard deviation = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 (10.3%); 96 had VI from URE (8.2%), 168 (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI from URE reported having a college degree and a larger percentage reported income < $10 000 compared to participants with no or adequately corrected RE (3.2% versus 14.2%, P = 0.02; 45.5% versus 21.6%, respectively, P < 0.0001. Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (VFQ9 composite score 67.3 ± 19.6 versus 77.0 ± 14.4 versus 82.2 ± 13.3, respectively; P < 0.0001). 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical shop with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement.

BACKGROUND: Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use. OBJECTIVE: To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults. DESIGN: We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates. PARTICIPANTS: Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement. MAIN MEASURES: Self-reported visits to the emergency department and nights spent hospitalized. RESULTS: Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25). CONCLUSION: Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.

Transportation Justice and Health.

Policy Points The health care sector is increasingly investing in social conditions, including availability of safe, reliable, and adequate transportation, that contribute to improving health. In this paper, we suggest ways to advance the impact of transportation interventions and highlight the limitations of how health services researchers and practitioners currently conceptualize and use transportation. Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy.

Assessing New York City's COVID-19 Vaccine Rollout Strategy: A Case for Risk-Informed Distribution.

This study reviews the impact of eligibility policies in the early rollout of the COVID-19 vaccine on coverage and probable outcomes, with a focus on New York City. We conducted a retrospective ecological study assessing age 65+, area-level income, vaccination coverage, and COVID-19 mortality rates, using linked Census Bureau data and New York City Health administrative data aggregated at the level of modified zip code tabulation areas (MODZCTA). The population for this study was all individuals in 177 MODZCTA in New York City. Population data were obtained from Census Bureau and New York City Health administrative data. The total mortality rate was examined through an ordinary least squares (OLS) regression model, using area-level wealth, the proportion of the population aged 65 and above, and the vaccination rate among this age group as predictors. Low-income areas with high proportions of older people demonstrated lower coverage rates (mean vaccination rate 52.8%; maximum coverage 67.9%) than wealthier areas (mean vaccination rate 74.6%; maximum coverage 99% in the wealthiest quintile) in the first 3 months of vaccine rollout and higher mortality over the year. Despite vaccine shortages, many younger people accessed vaccines ahead of schedule, particularly in high-income areas (mean coverage rate 60% among those 45-64 years in the wealthiest quintile). A vaccine program that prioritized those at greatest risk of COVID-19-associated morbidity and mortality would have prevented more deaths than the strategy that was implemented. When rolling out a new vaccine, policymakers must account for local contexts and conditions of high-risk population groups. If New York had focused limited vaccine supply on low-income areas with high proportions of residents 65 or older, overall mortality might have been lower.

Understanding social risk factors in patients presenting to the emergency Department for Acute Heart Failure: A pilot study.

BACKGROUND: The standard of care for congestive heart failure (CHF) aims to slow disease progression and maximize patient function, however there is an increase in emergency department (ED) revisits and readmissions. Social risk factors play a role in the disease management and prognosis of CHF. There is a gap in the identification of low-risk CHF patient who would be safely discharged using an initial social risk factor stratification. OBJECTIVES: To generate a social risk profile for patients presenting to the ED with acute CHF exacerbation and identify variables that may increase the risk of 7-day and overall mortality, 30-day ED revisit, and readmission. METHODS: We conducted a pilot prospective survey-based study among adult patients presenting to the ED with acute CHF exacerbation. The combination of a self-report questionnaire and retrospective chart review was used to generate a CHF risk profile. RESULTS: A total of 62 patients were recruited in the pilot study with a mean age of 69.5 years. The preliminary data indicated that prior to this ED visit, 21% of patients were not aware of a previous CHF diagnosis; 64.5% of patients rated their sleep quality as poor or very poor; 72.6% reported orthopnea; and 43.5% reported recent weight gain. 37.1% of patients did not adhere to dietary recommendations and some patients did not adhere to their medication regime 100%. CONCLUSION: This study suggests establishing a social risk profile for patients presenting to the ED with CHF can help formulate a CHF-specific care plan and optimize multidisciplinary management to reduce ED revisits and readmissions.

The relationship between community social risk factors and regional hospital-reported cash, negotiated, and chargemaster prices for 14 common services.

BACKGROUND: Social risk factors are key drivers of the geographic variation in spending in the United States but little is known how community-level social risk factors are associated with hospital prices. Our objective was to describe the relationship between regional hospital-reported prices and social risk factors by price type (chargemaster, cash, commercial, Medicare, and Medicaid). METHODS: This cross-sectional analysis used newly available hospital-reported prices from acute general hospitals in 2022. The prices were for 14 common services. Prices were winsorized at 98%, wage index-adjusted, standardized by service, and aggregated to hospital service areas (HSAs). For social risk, we used 23 measures across 5 domains of social risk (socioeconomic position; race, ethnicity, and culture; gender; social relationships; and residential and community context). Spearman's correlation was used to estimate associations between median prices and social risk by price type. RESULTS: Prices were reported from 2,386 acute general hospitals in 45% (1,502 of 3,436) HSAs. Correlations between regional prices and other social risk factors varied by price type (range: -0.19 to 0.31). Chargemaster and cash prices were significantly correlated with the most community characteristics (10 of 23, 43%) followed by commercial prices (8, 35%). Medicare and Medicaid prices were only significantly correlated with 1 measure (all p < 0.01). All price types were significantly correlated with the percentage of uninsured (all p < 0.01). Chargemaster, cash, and commercial prices were positively correlated with percentage of Hispanic residents, residents with limited English proficiency, and non-citizens (all p < 0.05). CONCLUSIONS: While regional correlations between prices and social risk factors were weak across all prices, chargemaster, cash, and commercial prices were more like closely aligned with community-level social risk factors than the two public payers (Medicare and Medicaid). Chargemaster, cash, and commercial hospital prices appeared to be higher in socially disadvantaged communities. Further research is needed to clarify the relationship between prices and community social risk factors.

Understanding the relationship between social risk factors and functional limitation among stroke survivors in the US.

BACKGROUND: Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown. METHODS: Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates. RESULTS: Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82). CONCLUSIONS: Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors.

Predicting attachment in Portuguese infants born very or extremely preterm: Understanding the roles of infant regulatory behavior, maternal sensitivity, and risk factors.

A growing body of research shows that early attachment relationships are foundational for children's later developmental and psychosocial outcomes. However, findings are mixed regarding whether preterm birth predicts later attachment, but insecurity is generally more prevalent among infants at higher medical and/or social/familial risk. This longitudinal study aimed to identify specific relational, familial/demographic, and perinatal predictors of attachment in a sample of 63 Portuguese infants born very or extremely preterm (VEPT, <32 gestational weeks) and their mothers from diverse socioeconomic backgrounds. One-third of the mothers had social/family risk factors (e.g., single parent, immigrant, unemployed, low education, and/or low income). At 3 months (corrected age), dyads were observed during social interaction in the Face-to-Face Still-Face paradigm (FFSF) and during free play. At 12 months, mother-infant dyads were observed in Ainsworth's Strange Situation. Over half (58.7%) of the infants were classified as insecurely attached. Social-Positive Oriented regulatory behavior pattern, higher maternal sensitivity, higher infant cooperation during free play, number of siblings and an absence of social/family risk factors were associated with attachment security. Perinatal variables were unrelated to attachment. Findings indicate that both relational and social contextual factors contribute to attachment in this biologically vulnerable sample.

Un creciente cuerpo investigativo muestra que las relaciones afectivas tempranas son fundamentales para posteriores resultados de desarrollo y sicosociales de los niños. Sin embargo, los resultados son variados acerca de si el nacimiento prematuro predice la afectividad posterior, pero la inseguridad es generalmente más prevalente entre infantes bajo más alto riesgo médico y/o social/familiar. Este estudio longitudinal se propuso identificar factores específicos de predicción de la afectividad, relacionales, familiar/demográficos y perinatales en un grupo muestra de 63 infantes portugueses nacidos muy o extremadamente prematuros (VEPT, < 32 semanas gestacionales) y sus madres de diversos niveles socioeconómicos. Un tercio de las madres tenían factores de riesgo social/familiar (v.g. madre soltera, inmigrante, desempleada, de baja educación y/o de bajos recursos económicos). A los tres meses (edad corregida), se les observó a las díadas durante la interacción social en el paradigma de Cara a Cara y Rostro Inmutable (FFSF) y durante el juego libre. A los 12 meses, se les observó a las díadas madre-infante por medio de la Situación Extraña de Ainsworth. Se clasificó más de la mitad (58.7%) de los infantes como afectivamente inseguros. Entre los factores de predicción de la afectividad segura se incluyó un patrón de conducta regulatoria con orientación social positiva durante FFSF, una sensibilidad materna más alta y la cooperación del infante durante el juego libre, así como la ausencia de factores de riesgo sociales/familiares. Las variables perinatales no estuvieron relacionadas con la afectividad. Los resultados indican que los factores contextuales, tanto relacionales como sociales contribuyen a la afectividad en este grupo biológicamente vulnerable.

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.

Implementing a Social Needs Screening and Referral Program Among Veterans: Assessing Circumstances & Offering Resources for Needs (ACORN).

BACKGROUND: The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs). OBJECTIVES: To (1) develop a process for systematically identifying and addressing Veterans' HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans. DESIGN: "Assessing Circumstances and Offering Resources for Needs" (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences. PARTICIPANTS: Convenience sample of Veterans presenting for primary care at a VA urban women's health clinic and suburban community-based outpatient clinic (October 2019-May 2020). MAIN MEASURES: Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis. KEY RESULTS: Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews (n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future. CONCLUSION: In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations.

BACKGROUND: Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs. OBJECTIVE: To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs. DESIGN: We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework. PARTICIPANTS: Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted. APPROACH: Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes. KEY RESULTS: Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support. CONCLUSIONS: VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

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.

A Survey of the National Comprehensive Cancer Network on Approaches Toward Addressing Patients' Transportation Insecurity.

BACKGROUND: Addressing patients' social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied. METHODS: In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN's 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future. RESULTS: A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients' transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%). CONCLUSIONS: Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients' transportation needs.

Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs.

INTRODUCTION: Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS: Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS: Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS: Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.

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.

Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review.

PURPOSE: Integrating social care into clinical care requires substantial resources. Use of existing data through a geographic information system (GIS) has the potential to support efficient and effective integration of social care into clinical settings. We conducted a scoping literature review characterizing its use in primary care settings to identify and address social risk factors. METHODS: In December 2018, we searched 2 databases and extracted structured data for eligible articles that (1) described the use of GIS in clinical settings to identify and/or intervene on social risks, (2) were published between December 2013 and December 2018, and (3) were based in the United States. Additional studies were identified by examining references. RESULTS: Of the 5,574 articles included for review, 18 met study eligibility criteria: 14 (78%) were descriptive studies, 3 (17%) tested an intervention, and 1 (6%) was a theoretical report. All studies used GIS to identify social risks (increase awareness); 3 studies (17%) described interventions to address social risks, primarily by identifying relevant community resources and aligning clinical services to patients' needs. CONCLUSIONS: Most studies describe associations between GIS and population health outcomes; however, there is a paucity of literature regarding GIS use to identify and address social risk factors in clinical settings. GIS technology may assist health systems seeking to address population health outcomes through alignment and advocacy; its current application in clinical care delivery is infrequent and largely limited to referring patients to local community resources.

Work as a social risk factor in pregnancy: A systematic review of screening practices related to working conditions and family leave among pregnant adults.

BACKGROUND: Paid family leave and working conditions are components of employment quality-a key social determinant of health across the life course, particularly during pregnancy. Increased research on prenatal social risk screening has not extended to employment quality. The objective of this systematic review was to identify prenatal screening practices and interventions in health care settings that address employment and working conditions as social risk factors among pregnant adults and to describe their properties and key findings. METHOD: We searched MEDLINE, PsychINFO, SocINDEX, EMBASE, and the SIREN Evidence and Resource Library for studies published through February 14, 2022. We selected multiple search terms related to four domains: (1) employment or working conditions; (2) screening; (3) health care settings; and (4) pregnancy or maternal health. RESULTS: Of the 2317 unique titles and abstracts that were potentially relevant, eight articles met all inclusion criteria and focused on pregnant populations. The content of identified screening practices varied substantially, highlighting the multiple ways employment is conceptualized as a potential risk factor. Few studies included multidimensional measures of employment to assess working conditions, which may be particularly relevant during pregnancy. CONCLUSIONS: Our review suggests that screening for employment as a social risk factor does not regularly occur in prenatal care. Although pragmatic properties of the screening tools we assessed are promising, tools seldom examine the multidimensional nature of work. Understanding the principal intent of screening for employment prenatally could provide greater opportunity to collect and interpret contextual factors that influence how both providers and patients respond to social risk.

Misuse of Pregabalin: a qualitative study from a patient's perspective.

INTRODUCTION: The misuse of Pregabalin has been the subject of growing concern for several years. The effects sought are multiple and it is rarely taken as a single drug. It is most frequently used together with opioids, which may increase the risk of fatal overdose. In response to this emerging phenomenon, we seek to better understand the situation of misuse in Belgium and identify the people involved in it. METHODOLOGY: A qualitative study using semi-structured interviews with 20 participants who misuse Pregabalin was conducted throughout the French-speaking region of Belgium between August 2021 and January 2022. Recruitment mostly took place in addictions centers, shelters for migrants and homeless persons and primary care centers. We then conducted a thematic analysis with the help of Nvivo software. RESULTS: A profile emerged, of young male users, immigrants, mainly first generation immigrants coming from North Africa. They had in common a challenging or even traumatic migration pathway and precarious living conditions in Belgian territory. Most of them had no stable income. They saw Pregabalin as enabling them to cope with their daily situation. All had psychiatric and/or somatic comorbidities for which they had apparently not recieved adequate medical care. This seemed to lead many of them to use Pregabalin as self-medication, for anxiety-depressive disorders and chronic pain, and it was sometimes initiated in their home country. Pregabalin was never used alone. CONCLUSION: This study has highlighted a rare and insufficient documented profile of Pregabalin misuse: self-medication among a group of first generation immigrants, most of whom have no previous history of opioid-related disorders. Measures should be taken to improve access to health and social care for this population, considering all their biopsychosocial vulnerabilities.

Social Risk Factors That Increase Cardiovascular and Breast Cancer Risk.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) and breast cancer (BC) are significant causes of mortality globally, imposing a substantial health burden. This review article aims to examine the shared risk factors and social determinants that contribute to the high prevalence of both diseases, with a focus on social risk factors. RECENT FINDINGS: The common risk factors for CVD and BC, such as hypertension, diabetes, obesity, aging, and physical inactivity, are discussed, emphasizing their modifiability. Adhering to ideal cardiovascular health behaviors has shown a trend toward lower BC incidence. Increased risk of CVD-related mortality is significantly impacted by age and race in BC patients, especially those over 45 years old. Additionally, racial disparities in both diseases highlight the need for targeted interventions. Social determinants of health, including socioeconomic status, education, employment, and neighborhood context, significantly impact outcomes for both CVD and BC. Addressing social factors is vital in reducing the burden of both CVD and BC and improving overall health equity.

Topic and Trend Analysis of Weibo Discussions About COVID-19 Medications Before and After China's Exit from the Zero-COVID Policy: Retrospective Infoveillance Study.

BACKGROUND: After 3 years of its zero-COVID policy, China lifted its stringent pandemic control measures with the announcement of the 10 new measures on December 7, 2022. Existing estimates suggest 90%-97% of the total population was infected during December. This change created a massive demand for COVID-19 medications and treatments, either modern medicines or traditional Chinese medicine (TCM). OBJECTIVE: This study aimed to explore (1) how China's exit from the zero-COVID policy impacted media and the public's attention to COVID-19 medications; (2) how social COVID-19 medication discussions were related to existing model estimates of daily cases during that period; (3) what the diversified themes and topics were and how they changed and developed from November 1 to December 31, 2022; and (4) which topics about COVID-19 medications were focused on by mainstream and self-media accounts during the exit. The answers to these questions could help us better understand the consequences of exit strategies and explore the utilities of Sina Weibo data for future infoveillance studies. METHODS: Using a scrapper for data retrieval and the structural topic modeling (STM) algorithm for analysis, this study built 3 topic models (all data, before a policy change, and after a policy change) of relevant discussions on the Chinese social media platform Weibo. We compared topic distributions against existing estimates of daily cases and between models before and after the change. We also compared proportions of weibos published by mainstream versus self-media accounts over time on different topics. RESULTS: We found that Weibo discussions shifted sharply from concerns of social risks (case tracking, governmental regulations, etc) to those of personal risks (symptoms, purchases, etc) surrounding COVID-19 infection after the exit from the zero-COVID policy. Weibo topics of "symptom sharing" and "purchase and shortage" of modern medicines correlated more strongly with existing susceptible-exposed-infected-recovered (SEIR) model estimates compared to "TCM formulae" and other topics. During the exit, mainstream accounts showed efforts to specifically engage in topics related to worldwide pandemic control policy comparison and regulations about import and reimbursement of medications. CONCLUSIONS: The exit from the zero-COVID policy in China was accompanied by a sudden increase in social media discussions about COVID-19 medications, the demand for which substantially increased after the exit. A large proportion of Weibo discussions were emotional and expressed increased risk concerns over medication shortage, unavailability, and delay in delivery. Topic keywords showed that self-medication was sometimes practiced alone or with unprofessional help from others, while mainstream accounts also tried to provide certain medication instructions. Of the 16 topics identified in all 3 STM models, only "symptom sharing" and "purchase and shortage" showed a considerable correlation with SEIR model estimates of daily cases. Future studies could consider topic exploration before conducting predictive infoveillance analysis, even with narrowly defined search criteria with Weibo data.