Accounting for Social Risk Factors in Medicare Payment Identifying Social Risk Factors (2016) / Chapter Skim
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2 Social Risk Factors
2 Social Risk Factors
Pages 47-84
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The five social risk factors may also influence health literacy, the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (NASEM, 2015)
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DEFINITIONS AND LITERATURE SEARCH In this section, the committee defines each of these five social risk factor domains, as well as health literacy, and summarizes the results of the literature search linking effects of each domain on health care outcomes and quality measures. Within each factor, results of review articles are discussed first, followed by results from individual studies.
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, one study found that low income was significantly associated with chronic obstructive pulmonary disease (COPD) exacerbations requiring hospitalization or an emergency department (ED)
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. In terms of patient experience, one study found that excellent ratings of care were significantly lower among colorectal cancer patients, but not among lung cancer patients, and also reported no differences in experiences of interpersonal care by income (Ayanian et al., 2010)
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• The committee identified literature indicating that when measured by a proxy of insurance status, income may influence health care utilization, clinical processes of care, and patient experience. Education Education is important for health, because it shapes future economic resources, including income and occupation (Adler and Newman, 2002; IOM, 2014a)
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. The committee made the following finding: • The committee identified literature indicating that occupation may influence health care utilization, health outcomes, and patient experience.
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. Several review articles examined race and ethnicity effects on health care use and health care outcomes.
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. In terms of other utilization outcomes, one study found that blacks had significantly increased all-cause hospitalization over 2.5 year follow up of heart failure patients (Mentz et al., 2013)
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. One study found a significant interaction between race/ethnicity and comorbidity among Medicare beneficiaries, where lower rates of flu and pneumonia immunization among racial/ethnic minorities decreases relative to white beneficiaries as the burden of comorbidity increases (Orr et al., 2013)
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In terms of post-acute outcomes, one study reported that blacks, Hispanics, and other non-whites had significantly worse functional outcomes after stroke (Ottenbacher et al., 2008) , but another study found no significant differences in functional status at discharge between black and whites after a moderate or severe stroke (Putman et al., 2010)
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. One study found that black, Hispanic, and Asian/Pacific Islander Medicare beneficiaries reported significantly poorer experiences with Part D prescription drug plans (Haviland et al., 2012)
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. The committee made the following finding: • The committee identified literature indicating that race and ethnicity may influence health care utilization, clinical processes of care, costs, health outcomes, patient safety, and patient experience.
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. The committee made the following finding: • The committee identified literature indicating that language may influence health care utilization, clinical processes of care, health outcomes, and patient experience.
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The committee made the following finding: • The committee identified literature indicating that nativity may influence clinical processes of care and patient experience. Gender Gender is associated with many health and health care–related outcomes (IOM, 2014a)
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. The committee made the following finding: • The committee identified literature indicating that gender may influence clinical processes of care and patient experience.
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. The committee made the following finding: • The committee identified literature indicating that marital status may influence health care utilization, clinical processes of care, costs, health outcomes, and patient experience.
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The committee made the following finding: • The committee identified literature indicating that living alone may influence health care utilization, clinical processes of care, and health outcomes. Social Support Social support is a key function of social relationships and includes the provision of emotional and appraisal support through caring and concern, as well as more tangible instrumental and informational support such as the provision of material or other practical support (House et al., 1988b)
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found that among breast cancer patients some types of social support but not others were associated with satisfaction with their physician and problems interacting with their medical team. The committee made the following findings: • The committee identified literature indicating that social support may influence heath care utilization, clinical processes of care, health outcomes, and patient experience.
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One study found that low neighborhood SEP was associated with significantly greater odds of operative death (Birkmeyer et al., 2008) , and another found that below-average neighborhood SEP composition was associated with increased mortality 1-year after heart failure, but not with 30-day mortality (Rathore et al., 2006)
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. One study found that town-level poverty was predictive of AMI and heart failure hospitalizations (Harris et al., 2008)
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Other compositional factors Two studies examined the effect of other compositional factors on health care use. One article found that the percent of residents never married, the number of Medicare beneficiaries per capita, the number of nursing home residents with pressure sores, and the number of nursing home residents with increased need for help were associated with increased readmissions for AMI, heart failure, and pneumonia, whereas the number of nursing home patients who were depressed or anxious was associated with decreased risk of readmission (Herrin et al., 2015)
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One study found no association between distance traveled and readmissions (Chou et al., 2014) , while another reported that distance traveled relative to the patient mean distance was significantly associated with increased likelihood of 30-day readmission (Kroch et al., 2015)
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Most studies of health care use and health care outcomes focused on utilization. One study found that rural residence was associated with decreased risk of readmission (Herrin et al., 2015)
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It does so also because it is affected by social risk factors, and the literature supports a role for health literacy in health care outcomes and quality measures. The committee also included numeracy as a related concept.
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The committee made the following finding: • The committee identified literature indicating that health literacy may influence health care utilization, clinical processes of care, cost, and patient experience. CONCLUDING REMARKS It is important to note that although often correlated (e.g., SEP is correlated with race/ethnicity and both race/ethnicity and income are correlated with community context)
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2015. Health literacy and 30-day hospital readmission after acute myocardial infarction.
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2013. Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: Systematic review.
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2015. Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: Evidence from a systematic review.
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2011. Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization atherosclerosis risk in communities cohort (1987 to 2004)
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2008. Myocardial infarction and heart failure hospitalization rates in Maine, USA -- variability along the urban–rural continuum.
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2014b. Health literacy and numeracy: Workshop summary.
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2005. The importance and impact of social support on outcomes in patients with heart failure: An overview of the literature.
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2004. Social support and its relationship to morbidity and mortality after acute myocardial infarction: Systematic overview.
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2001. Socioeconomic status as an independent risk factor for hospital readmission for heart failure.
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2011. Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction.
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2012. The impact of social support on outcomes in adult patients with type 2 diabetes: A systematic review.
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2013. Effect of marital status on clinical outcome of heart failure.
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2008. Medication adherence in patients who have heart failure: A review of the literature.
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