Measuring Social Determinants of Health
The adage stating “what gets measured gets improved” evidently inspired a group from Riverside [CA] University Health System (RUHS) to develop a comprehensive measurement tool for use in care of persons assigned to their system. The report, which is very much a work in progress, has been re-published in February 2023. 1 In brief, the group
developed and tested a 28-question instrument that mapped to six domains: physical health, emotional health, resource utilization, socioeconomics, ownership, and nutrition/lifestyle. In order to make the information actionable, outcomes are plotted along a 26-letter scale which is then stratified into tertiles denoted as red, yellow, and green
In order to understand the results presented in the article, it is necessary to know something about RUHS. RUHS is operated by Riverside County, California, and has 6,000 employees working in a 439-bed hospital and 13 community health centers. The staff in the community centers are grouped into specialized teams. All 13 locations have primary care
medical homes supported by both behavioral specialists and dietitians and health coaches in addition to physicians and nurses. Eight locations have teams focused on care of persons on parole following incarceration, and eleven have teams focused on complex care management. So, they have built a system with more robust behavioral care and care management staff than most medical organizations.
Between August 2020 and October 2021, the height of the pandemic disruption, they obtained completed 9,809 surveys in 8,829 individuals. (They designed the instrument to be applied serially.) They limited analysis to the 7,926 individuals who completed only one survey. 5,504 had no red-zone triggers; the remainder had anywhere from one to six red-zone triggers in a declining frequency as would be expected. Just under
half the red-zone triggers were in the nutrition lifestyle domain, or 15.22% of the surveyed group; emotional health in 10.59% of the group; and socioeconomics in 9.35% of the group.
The authors conclude their instrument worked and provide anecdotal evidence that it led to effective intervention, but admit their data are exploratory. So, it remains an open question as to whether the effort is likely to lead to improvement in outcomes, even in their
own system with its built-in psychiatric, psychological, and behavioral resources. My own experience attempting population health using scarce, community-based resources makes me even more skeptical. High-utilizers with possibly preventable costs focus around those patients with the same issues—behavioral and nutritional health as well as substance use
disorders. So, how effective are available therapies?
The recent school shooting tragedy in Nashville involved a person who grew up in my community, so it has been much discussed here. Independently of the contentious politics of gun control, there have been the usual calls for “more mental health care resources.” Of course, this is proposed by politicians with no insight into what that might mean or how it could be accomplished, much less whether it would actually help or not.
1 NEJM Catalyst. Editors’ Picks of 2022. Downloaded from catalyst.nejm.org., March 2023, pp. 1-29. Original
article Kurana D, Leung G, Sasaninia B, Tran D, Khan M, Firek A. The Whole PERSON Health Score: A Patient-
Focused Tool to Measure Nonmedical Determinants of Health. NEJM Catalyst 2022;3, (August 2022.)
There are also data suggesting a pandemic-associated increase in what might be called mental malaise. There are effective therapies for trauma-associated anxiety and depression, which are often needed on a short-term basis and do not involve medication.
But for a population-wide phenomenon like the pandemic, do we need “professionals” or do we need community-based support for those who have not been able to recover?
Treating mental health disorders is similar to most medical therapy—we have preventive therapy for a few things, curative therapy for a few things, and palliative maintenance therapy for a lot of conditions. But even so, there are individuals with more severe cases or
who, for one reason or another, fail to respond in the usual fashion.
The other challenge, particularly when addressing social determinants, is that “fixing” some of the deficits might be nice, appropriate, or good, from the perspective of the
outsider, but there is not much evidence that it changes anything. Certainly, hunger, and being cold aren’t good, but I continue to worry that we are engaged in medical, and cultural, imperialism, when we who are “outsiders,” or as we might say, “experts,” presume to know
what other people want or need.
While there has been a lot of emphasis on diversity, equity, and inclusion, much of this ignores the fact that virtually everyone is part of a culture which dictates more than we might realize about what we consider acceptable. I have told the story before, but it bears repeating. Many years ago, my church in San Antonio, consisting mainly of “Anglos,” had a
food drive at Thanksgiving for people living in poverty in the southwestern area of town, consisting mainly of people of Mexican ancestry. Some in my congregation were incensed when the pumpkin pie filling was left in the box, not recognizing it was not part of local culture. There was simply no folklore involving pumpkin pie filling. This is not to say starvation is good, but giving people something to eat works better if it is familiar.
Conversely, getting people to give up traditional foods because they are unhealthy is equally difficult. What do you do on your traditional feast days? I daresay most of us eat what grandma used to cook.
Measuring the impact of social determinants of health, broadly defined, is useful in that it illustrates the limits of the medical model. I remember having lunch with a senior physician who was bemoaning the changes he had seen. He said when he was younger, people had marital or family problems, money problems, or were alcoholics. Now everyone
had “low self-esteem” and wanted a prescription for Valium. And this was forty years ago.
We can define poverty and discrimination in medical terms and in terms of impact on individual health, but does it help or distract from our historic task of trying to improve physical and mental health in ill or injured patients? I don’t know, but I fear it only serves to make a difficult task impossible.
Accountable Health Communities
CMS has announced funding of the "Accountable Health Communities" initiative. Creative problem solving or misguided government interference?
"Hotspotting" is a new term for an old idea, but it usually means identifying and intervening on patients who are, or at risk for becoming, superutilizers. But are we asking the right questions?
Population health is a phrase that disguises some hard realities as illustrated by two recent reports.
Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice
Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem.
Social Determinants of Health
Social determinants of health trump many medical therapies, but can changes be made that result in better health?
Our current cultural norms make following traditional medical advice, like eating less and exercising more, difficult for most people to do. Improving health may have more to do with modifying these forces, which is beyond the competence of health care providers and organizations.