Health-related socioeconomic risk screening in outpatient obstetrics and gynecology practice

Abstract

ObjectiveThe COVID-19 pandemic has exacerbated socioeconomic barriers to health among people seeking obstetrical and gynecologic care, including cisgender women and transgender patients.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar Increased socioeconomic vulnerability in these populations is associated with alarmingly high rates of mental health problems observed during the pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar The American College of Obstetricians and Gynecologists (ACOG) recommends that healthcare providers screen and refer for health-related socioeconomic risk factors (HRSRs) as a means to provide more effective care, improve individual health outcomes, and reduce population-level inequities in reproductive health.3Committee on Health Care for Underserved WomenACOG Committee Opinion No. 729: importance of social determinants of health and cultural awareness in the delivery of reproductive health care.Obstet Gynecol. 2018; 131: e43-e48Crossref PubMed Scopus (63) Google Scholar Previous studies have established the appropriateness of HRSR screening among primary care patients and caregivers of pediatric patients.4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar To complement the ACOG recommendation, this study examined how obstetrical and gynecologic patients perceive HRSR screening and documentation.Study DesignA cross-sectional convenience sample of patients was recruited from urban, academic obstetrical and gynecologic clinics between April 2019 and June 2019. Eligible participants were English- or Spanish-speaking patients aged ≥18 years and able to provide informed consent. Potential participants were approached in clinic waiting areas, provided with information about the study, and screened for eligibility if interested. Eligible participants completed a self-administered survey assessing sociodemographic characteristics, HRSR status, and attitudes toward HRSR screening and documentation in electronic health records (EHRs). All participants provided verbal confirmation of the informed consent process. The protocol was approved by the institutional review board. Descriptive statistics were used to summarize survey responses across all patients and stratified by HRSR status (no HRSR or ≥1 HRSR).ResultsOf the 133 patients who expressed interest when approached, 79 met eligibility criteria and were included in the sample. Moreover, 47% of patients reported ≥1 HRSR, including food insecurity (33%), housing instability (25%), transportation difficulties (22%), utilities difficulties (13%), and interpersonal violence (1%) (Table). The desire for assistance with HRSRs was endorsed by 90% of patients with utilities difficulties (n=9), 65% of patients with housing instability (n=13), and 73% of patients with food insecurity (n=19). Among all patients with ≥1 HRSR, 60% desired assistance with HRSRs (32% overall), 72% were comfortable with EHR documentation (66% overall), and 92% felt it was appropriate to assess for HRSRs in clinical settings (82% overall).TableSample characteristics of obstetrics and gynecology patientsCharacteristicsTotal (N=79)N%Age (n=77) 18–44 y6483 45–64 y1216 ≥65 y11Gender Cisgender woman7899 Transgender man11Race Black4862 White2228 OtheraIncludes participants self-identifying as Asian, >1 race, or other unspecified race.810Education Less than high school or high school2025 Greater than high school4975Income (n=67) ≤$25,0002639 >$25,0004161HRSRs Food insecurity2633 Transportation difficulties1722 Utilities difficulties1013 Housing instability2025 Interpersonal violence11Number of HRSRs No HRSR4253 ≥1 HRSR3747Desiring HRSR assistance No5468 Yes6532Appropriateness of HRSR screening Inappropriate1418 Appropriate6582Comfort with EHR documentation (n=77) Uncomfortable2634 Comfortable5166EHR, electronic health record; HRSR, health-related socioeconomic risk factor.Pinkerton. Social risk screening in obstetrics and gynecology. Am J Obstet Gynecol 2022.a Includes participants self-identifying as Asian, >1 race, or other unspecified race. Open table in a new tab ConclusionConsistent with the ACOG recommendations and studies of other patient populations,4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar most obstetrical and gynecologic patients felt that HRSR screening in a clinical setting was appropriate and were comfortable with EHR documentation. Most patients with HRSRs desired assistance. Although generalizability was limited by a small convenience sample and the single institution design, our findings support the US healthcare sector's investment in social care integration. The National Academies of Science, Engineering, and Medicine's social care framework5National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s HealthIntegrating social care into the delivery of health care: moving upstream to improve the nation’s health. National Academies Press, Washington, DC2019Google Scholar emphasizes the importance of not only assessing HRSRs but assisting patients to mitigate health-related socioeconomic vulnerability, a prevalent condition among people presenting for obstetrical and gynecologic care before and during the COVID-19 pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar To enable systematic assessment and assistance, our team developed the CommunityRx intervention. CommunityRx is an evidence-based, electronic medical record-integrated, and personalized community resource referral system that connects patients to resources in their community to address health-related social risk factors and wellness, disease self-management, and caregiving needs.6Lindau S.T. Makelarski J. Abramsohn E. et al.CommunityRx: a population health improvement innovation that connects clinics to communities.Health Aff (Millwood). 2016; 35: 2020-2029Crossref PubMed Scopus (51) Google Scholar ObjectiveThe COVID-19 pandemic has exacerbated socioeconomic barriers to health among people seeking obstetrical and gynecologic care, including cisgender women and transgender patients.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar Increased socioeconomic vulnerability in these populations is associated with alarmingly high rates of mental health problems observed during the pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar The American College of Obstetricians and Gynecologists (ACOG) recommends that healthcare providers screen and refer for health-related socioeconomic risk factors (HRSRs) as a means to provide more effective care, improve individual health outcomes, and reduce population-level inequities in reproductive health.3Committee on Health Care for Underserved WomenACOG Committee Opinion No. 729: importance of social determinants of health and cultural awareness in the delivery of reproductive health care.Obstet Gynecol. 2018; 131: e43-e48Crossref PubMed Scopus (63) Google Scholar Previous studies have established the appropriateness of HRSR screening among primary care patients and caregivers of pediatric patients.4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar To complement the ACOG recommendation, this study examined how obstetrical and gynecologic patients perceive HRSR screening and documentation. The COVID-19 pandemic has exacerbated socioeconomic barriers to health among people seeking obstetrical and gynecologic care, including cisgender women and transgender patients.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar Increased socioeconomic vulnerability in these populations is associated with alarmingly high rates of mental health problems observed during the pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar The American College of Obstetricians and Gynecologists (ACOG) recommends that healthcare providers screen and refer for health-related socioeconomic risk factors (HRSRs) as a means to provide more effective care, improve individual health outcomes, and reduce population-level inequities in reproductive health.3Committee on Health Care for Underserved WomenACOG Committee Opinion No. 729: importance of social determinants of health and cultural awareness in the delivery of reproductive health care.Obstet Gynecol. 2018; 131: e43-e48Crossref PubMed Scopus (63) Google Scholar Previous studies have established the appropriateness of HRSR screening among primary care patients and caregivers of pediatric patients.4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar To complement the ACOG recommendation, this study examined how obstetrical and gynecologic patients perceive HRSR screening and documentation. Study DesignA cross-sectional convenience sample of patients was recruited from urban, academic obstetrical and gynecologic clinics between April 2019 and June 2019. Eligible participants were English- or Spanish-speaking patients aged ≥18 years and able to provide informed consent. Potential participants were approached in clinic waiting areas, provided with information about the study, and screened for eligibility if interested. Eligible participants completed a self-administered survey assessing sociodemographic characteristics, HRSR status, and attitudes toward HRSR screening and documentation in electronic health records (EHRs). All participants provided verbal confirmation of the informed consent process. The protocol was approved by the institutional review board. Descriptive statistics were used to summarize survey responses across all patients and stratified by HRSR status (no HRSR or ≥1 HRSR). A cross-sectional convenience sample of patients was recruited from urban, academic obstetrical and gynecologic clinics between April 2019 and June 2019. Eligible participants were English- or Spanish-speaking patients aged ≥18 years and able to provide informed consent. Potential participants were approached in clinic waiting areas, provided with information about the study, and screened for eligibility if interested. Eligible participants completed a self-administered survey assessing sociodemographic characteristics, HRSR status, and attitudes toward HRSR screening and documentation in electronic health records (EHRs). All participants provided verbal confirmation of the informed consent process. The protocol was approved by the institutional review board. Descriptive statistics were used to summarize survey responses across all patients and stratified by HRSR status (no HRSR or ≥1 HRSR). ResultsOf the 133 patients who expressed interest when approached, 79 met eligibility criteria and were included in the sample. Moreover, 47% of patients reported ≥1 HRSR, including food insecurity (33%), housing instability (25%), transportation difficulties (22%), utilities difficulties (13%), and interpersonal violence (1%) (Table). The desire for assistance with HRSRs was endorsed by 90% of patients with utilities difficulties (n=9), 65% of patients with housing instability (n=13), and 73% of patients with food insecurity (n=19). Among all patients with ≥1 HRSR, 60% desired assistance with HRSRs (32% overall), 72% were comfortable with EHR documentation (66% overall), and 92% felt it was appropriate to assess for HRSRs in clinical settings (82% overall).TableSample characteristics of obstetrics and gynecology patientsCharacteristicsTotal (N=79)N%Age (n=77) 18–44 y6483 45–64 y1216 ≥65 y11Gender Cisgender woman7899 Transgender man11Race Black4862 White2228 OtheraIncludes participants self-identifying as Asian, >1 race, or other unspecified race.810Education Less than high school or high school2025 Greater than high school4975Income (n=67) ≤$25,0002639 >$25,0004161HRSRs Food insecurity2633 Transportation difficulties1722 Utilities difficulties1013 Housing instability2025 Interpersonal violence11Number of HRSRs No HRSR4253 ≥1 HRSR3747Desiring HRSR assistance No5468 Yes6532Appropriateness of HRSR screening Inappropriate1418 Appropriate6582Comfort with EHR documentation (n=77) Uncomfortable2634 Comfortable5166EHR, electronic health record; HRSR, health-related socioeconomic risk factor.Pinkerton. Social risk screening in obstetrics and gynecology. Am J Obstet Gynecol 2022.a Includes participants self-identifying as Asian, >1 race, or other unspecified race. Open table in a new tab Of the 133 patients who expressed interest when approached, 79 met eligibility criteria and were included in the sample. Moreover, 47% of patients reported ≥1 HRSR, including food insecurity (33%), housing instability (25%), transportation difficulties (22%), utilities difficulties (13%), and interpersonal violence (1%) (Table). The desire for assistance with HRSRs was endorsed by 90% of patients with utilities difficulties (n=9), 65% of patients with housing instability (n=13), and 73% of patients with food insecurity (n=19). Among all patients with ≥1 HRSR, 60% desired assistance with HRSRs (32% overall), 72% were comfortable with EHR documentation (66% overall), and 92% felt it was appropriate to assess for HRSRs in clinical settings (82% overall). EHR, electronic health record; HRSR, health-related socioeconomic risk factor. Pinkerton. Social risk screening in obstetrics and gynecology. Am J Obstet Gynecol 2022. ConclusionConsistent with the ACOG recommendations and studies of other patient populations,4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar most obstetrical and gynecologic patients felt that HRSR screening in a clinical setting was appropriate and were comfortable with EHR documentation. Most patients with HRSRs desired assistance. Although generalizability was limited by a small convenience sample and the single institution design, our findings support the US healthcare sector's investment in social care integration. The National Academies of Science, Engineering, and Medicine's social care framework5National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s HealthIntegrating social care into the delivery of health care: moving upstream to improve the nation’s health. National Academies Press, Washington, DC2019Google Scholar emphasizes the importance of not only assessing HRSRs but assisting patients to mitigate health-related socioeconomic vulnerability, a prevalent condition among people presenting for obstetrical and gynecologic care before and during the COVID-19 pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar To enable systematic assessment and assistance, our team developed the CommunityRx intervention. CommunityRx is an evidence-based, electronic medical record-integrated, and personalized community resource referral system that connects patients to resources in their community to address health-related social risk factors and wellness, disease self-management, and caregiving needs.6Lindau S.T. Makelarski J. Abramsohn E. et al.CommunityRx: a population health improvement innovation that connects clinics to communities.Health Aff (Millwood). 2016; 35: 2020-2029Crossref PubMed Scopus (51) Google Scholar Consistent with the ACOG recommendations and studies of other patient populations,4De Marchis E.H. Hessler D. Fichtenberg C. et al.Part I: a quantitative study of social risk screening acceptability in patients and caregivers.Am J Prev Med. 2019; 57: S25-S37Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar most obstetrical and gynecologic patients felt that HRSR screening in a clinical setting was appropriate and were comfortable with EHR documentation. Most patients with HRSRs desired assistance. Although generalizability was limited by a small convenience sample and the single institution design, our findings support the US healthcare sector's investment in social care integration. The National Academies of Science, Engineering, and Medicine's social care framework5National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s HealthIntegrating social care into the delivery of health care: moving upstream to improve the nation’s health. National Academies Press, Washington, DC2019Google Scholar emphasizes the importance of not only assessing HRSRs but assisting patients to mitigate health-related socioeconomic vulnerability, a prevalent condition among people presenting for obstetrical and gynecologic care before and during the COVID-19 pandemic.1Lindau S.T. Makelarski J.A. Boyd K. et al.Change in health-related socioeconomic risk factors and mental health during the early phase of the COVID-19 pandemic: a national survey of U.S. women.J Womens Health (Larchmt). 2021; 30: 502-513Crossref PubMed Scopus (15) Google Scholar,2Restar A.J. Jin H. Jarrett B. et al.Characterising the impact of COVID-19 environment on mental health, gender affirming services and socioeconomic loss in a global sample of transgender and non-binary people: a structural equation modelling.BMJ Glob Health. 2021; 6e004424Crossref Scopus (11) Google Scholar To enable systematic assessment and assistance, our team developed the CommunityRx intervention. CommunityRx is an evidence-based, electronic medical record-integrated, and personalized community resource referral system that connects patients to resources in their community to address health-related social risk factors and wellness, disease self-management, and caregiving needs.6Lindau S.T. Makelarski J. Abramsohn E. et al.CommunityRx: a population health improvement innovation that connects clinics to communities.Health Aff (Millwood). 2016; 35: 2020-2029Crossref PubMed Scopus (51) Google Scholar