Abstract
ImportanceWhile the association between Social Determinants of Health (SDOH) and health outcomes is well known, few studies have explored the impact of SDOH on hospitalization.ObjectiveExamine the independent association and cumulative effect of six SDOH domains on hospitalization.DesignUsing cross-sectional data from the 2016–2018 National Health Interview Surveys (NHIS), we used multivariable logistical regression models controlling for sociodemographics and comorbid conditions to assess the association of each SDOH and SDOH burden (i.e., cumulative number of SDOH) with hospitalization.SettingNational survey of community-dwelling individuals in the USParticipantsAdults ≥18 years who responded to the NHIS surveyExposureSix SDOH domains (economic instability, lack of community, educational deficits, food insecurity, social isolation, and inadequate access to medical care)MeasuresHospitalization within 1 yearResultsAmong all 55,186 respondents, most were ≤50 years old (54.2%), female (51.7%, 95% CI 51.1–52.3), non-Hispanic (83.9%, 95% CI 82.4–84.5), identified as White (77.9%, 95% CI 76.8–79.1), and had health insurance (90%, 95% CI 88.9–91.9). Hospitalized individuals (n=5506; 8.7%) were more likely to be ≥50 years old (61.2%), female (60.7%, 95% CI 58.9–62.4), non-Hispanic (87%, 95% CI 86.2–88.4), and identify as White (78.5%, 95% CI 76.7–80.3), compared to those who were not hospitalized. Hospitalized individuals described poorer overall health, reporting higher incidence of having ≥5 comorbid conditions (38.9%, 95% CI 37.1–40.1) compared to those who did not report a hospitalization (15.9%, 95% CI 15.4–16.5). Hospitalized respondents reported higher rates of economic instability (33%), lack of community (14%), educational deficits (67%), food insecurity (14%), social isolation (34%), and less access to health care (6%) compared to non-hospitalized individuals. In adjusted analysis, food insecurity (OR: 1.36, 95% CI 1.22–1.52), social isolation (OR: 1.17, 95% CI 1.08–1.26), and lower educational attainment (OR: 1.12, 95% CI 1.02–1.25) were associated with hospitalization, while a higher SDOH burden was associated with increased odds of hospitalization (3–4 SDOH [OR: 1.25, 95% CI 1.06–1.49] and ≥5 SDOH [OR: 1.72, 95% CI 1.40–2.06]) compared to those who reported no SDOH.ConclusionsAmong community-dwelling US adults, three SDOH domains: food insecurity, social isolation, and low educational attainment increase an individual’s risk of hospitalization. Additionally, risk of hospitalization increases as SDOH burden increases.
Highlights
Hospitalization is a costly resource that accounts for one-third of health care expenditures in the United States (US).[1]
Almost one-insix reported substance use (16%) or inadequate access to health care (13%). Those who reported a hospitalization in the previous year had higher rates in six of the social determinants of health (SDOH) domains, and reported less access to health care (6%) compared to non-hospitalized individuals
In this national survey assessment of community-dwelling US adults, we found that three self-reported SDOH domains: low educational attainment, food insecurity, and social isolation were significantly associated with hospitalization
Summary
Hospitalization is a costly resource that accounts for one-third of health care expenditures in the United States (US).[1] In recent years, health care institutions have placed a larger focus on hospitalization rates in response to financial penalties levied by Medicare’s Hospital Readmissions Reduction Program.[2] While a variety of clinical and epidemiologic factors impact this outcome, a growing body of evidence suggests that individual’s social determinants of health (SDOH)—defined by the World Health Organization as the “circumstances in which people are born, grow, work, live, and age and the systems put in place to deal with illness”— play a significant role.[3,4,5,6,7,8]. SDOH assessments are often nonspecific and lack granularity. Many assessments only examine general traits and characteristics (i.e., age, ethnicity, and insurance payor status) that are extractable through administrative or clinical data.[3,6,8] Such approaches frequently lack individual-level assessments (i.e., food insecurity, social isolation, educational background, and economic stability), which could provide a more granular understanding of an individual’s social risk. While general sociodemographic characteristics are helpful, their lack of specificity can lead to non-specific and nonactionable findings— hindering improvement efforts by health care systems and policy
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