Abstract
BackgroundHealth systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients’ Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients’ clinical condition.MethodsIn this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management.ResultsSocial needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950).ConclusionsAssociations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.
Highlights
Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients’ Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients’ clinical condition
Study sample Between May 2017 and February 2019, PRAPARE was delivered to 2192 patients, primarily those who were referred to behavioral health either as part of a primary care or stand-alone appointment (Table 1)
Our findings suggest that performance may depend on how clinical outcomes are defined and that relationships between social needs assessment data and outcomes vary by disease pathway
Summary
Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients’ Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients’ clinical condition. Drake et al BMC Cardiovasc Disord (2021) 21:342 social needs associated with downstream consequences of the SDOH [3, 4] To this end, health care systems and payers are increasingly collecting population- and individual-level data on social needs, including food insecurity, unemployment, housing instability, and transportation barriers [5, 6]. The PRAPARE screening assessment bridges social risk and clinical risk indicators by being embedded into electronic health record (EHR) systems and has facilitated national standards surrounding social risk data capture, reporting, and population health and care management activities [9]
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