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Social Determinants of Health
The influence of poverty, social norms, ethnic ancestry, and social policies have received new attention as their impact on outcomes during the coronavirus pandemic have been reported. For those in nephrology, though, this is not a new idea. We have long known, for instance, that patients with African ancestry are over-represented in dialysis populations as well as others from poorer socio-economic groups. Personally, I have cared for patients who did not complete sixth grade, who had not worked enough quarters/years with FICA withholding to qualify for Medicare, (plus the usual patients with cognitive impairment, mental illness, and/or chemical dependency.) Some of these problems are intractable, but others might be amenable to solutions, such as providing rides to appointments, paying for medication, rental assistance, co-pays, etc. Recently, Phil Galewitz wrote an article asking if spending money on patients’ social needs was working.[1] “In the past decade dozens of studies funded by state and federal governments, private hospitals, insurers, and philanthropic organizations have looked into whether addressing patients’ social needs improves health and lowers costs. But so far, it’s unclear which of these strategies, focused on so-called social determinants of health are most effective, or feasible according to several recent academic reports that evaluated existing research on the interventions… The new reports found that even when such interventions show promising results, they usually serve only a small number of patients. Another challenge is that several studies did not go on long enough to detect an impact, or they did not evaluate health outcomes or health costs.” He then proceeds to note several specific examples of studies, including California’s plan to revamp Medicaid spending and a similar effort in North Carolina. He notes: “The move to address social needs is gaining steam nationally because, after nearly a dozen years focused on expanding insurance under the Affordable Care Act, many experts and policymakers agree that simply increasing access to health care is not nearly enough to improve patients’ health. That’s because people don’t need just access to doctors, hospitals, and drugs, to be healthy, they need healthy homes, healthy food, adequate transportation and education, a steady income, safe neighborhoods, and a home life free from domestic violence—things hospitals and doctors can’t provide, but in the long run, are as meaningful as an antibiotic or an annual physical.” As a global proposition, these items are certainly desirable, but it is something that should be evaluated on its own merits, not tied to improving health or reducing health care costs. I am skeptical that any or all of these interventions will have much impact on individual health status. Recently, I had a patient presented to me who was in her early 40’s, intellectually disabled, and suffering from diabetes, hypertension, and chronic kidney disease. The case manager had been involved because she had been admitted three times in the past few months with complications related to inadequate control of her diseases. The case manager described all of the interventions she had tried, but readily admitted she did not think her efforts had borne any fruit. She was looking for some brilliant stratagem from me, but I asked her if she thought we would be more successful trying to adapt the patient to the medical regimen, or adapt the medical regimen to the patient’s capabilities? I bring this up because many efforts to address social determinants of health may be trying to adapt the people to the “medical” regimen, not the other way around. On interesting exception is a study of hypertension control in black men using barbershops as the locus of care.[2] Recognizing the prevalence of untreated hypertension in black men the investigators knew a non-traditional approach was needed. For many black men, the barbershop is a social club as well as a place to get a haircut, and barbers are seen as trusted sources of information. “Barbers in shops assigned to the intervention were trained to encourage pharmacist follow-up and measure blood pressure… Participants in the control group received instruction about blood pressure. Barbers were trained to discuss the instructional information with participants and encourage follow-up with a provider…Among black men who were barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger reductions in blood pressure when coupled with drug therapy prescribed by specialty-trained pharmacists. The mean reductions in systolic and diastolic blood pressure were 21.6 and 14.9 mm Hg greater, respectively, in participants assigned to the pharmacist-led intervention than in those assigned to the active control. In the intervention group, the rate of cohort retention was 95%, there were few adverse events, and self-rated health and patient engagement increased.” Maybe there is a lesson here about being respectful of community norms, something that has to be learned by most missionaries and other NGO aid workers who set out to “do good.” Money is necessary, but not sufficient, to change community norms or to raise individual and community expectations about what is possible. Perhaps we should consider if we are suffering from medical cultural imperialism? 28 June 2021 [1] Galewitz P. In Health Care, More Money is Being Spent on Patients’ Social Needs. Is It Working? 21 June 2021. Accessed 22 June 2021 at https://www.npr.org/sections/health-shots/2021/06/21/998578876/in-health-care-more-money-is-being-spent-on-patients-social-needs-is-it-working. [2] Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J., et. al. A Cluster-Randomized Trial of Blood Pressure Reduction in Black Barbershops. N Engl J Med 2018;378(5 April 2018):1291-1301. doi: 10.1056/NEJMoa1717250. |
Further Reading
Population Health Population health is a phrase that disguises some hard realities as illustrated by two recent reports. Regret Regret is a universal emotion. Although we try, avoiding regret is not possible, and our desire to do so creates costs to everyone. Swimming Upstream 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. The Limits of the Medical Model The One Best Way What Matters What really matters to practicing physicians? |