Social Determinants of Health: Measuring What Matters

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Since the early 2000s, global health experts have recognized what we know as “social determinants of health” (SDOH) and understood the critical role they play in the health and wellbeing of populations. Collectively, SDOH is a broad range of economic and social conditions – adequate housing and nutrition, access to education, employment, and healthcare services, etc. – that have a profound influence on individual and group differences in health status. Although gradual steps have been taken to address SDOH, it took the COVID-19 pandemic and its disproportionate impact on Black and Hispanic individuals and low-income communities to reveal the full extent of inequality in the U.S. healthcare system.

What approaches do we have in place to address SDOH today and well beyond the COVID pandemic? For its part, the public health sector has been actively involved in promoting the inclusion of SDOH. The CDC has developed SDOH measures; for instance, its Prevention Status Reports (PSRs), a performance measurement system for all 50 states and the District of Columbia, examine the extent to which states are using evidence-based policies and practices, including SDOH, to address the nation’s most important health concerns. PSRs can be used to assess a state’s status and identify areas for improvement. And at the Department of Health and Human Services, the Office of Minority Health’s Division of Policy and Data is developing health policies and initiatives that are designed to address the elimination of health disparities and advance health equity.

The private sector also is getting involved in various ways:

Leveraging SDOH Data. Researchers at Vizient, a nonprofit healthcare performance improvement company (my institution, Thomas Jefferson University, is a member of their organization), noted that each patient with an acute condition also has a medical history (e.g., prior comorbidities, exposure risks) and that factors leading up to the point of the acute episode are important in analyzing its course. Using inpatient data from more than 550 member hospitals (March-September 2020), research staff identified racial and economic disparities in patients’ risk for COVID-19 diagnosis and admission — for example, patients in high-poverty areas were at higher risk for contracting COVID, and Black and Hispanic women of working age experienced higher rates of COVID. The bottom line is that SDOH data can be leveraged to improve health outcomes.

Social Determinants of Health Survey 2021. To assess how health systems are seeking to advance health equity, Vizient collected data from 76 organizations in 33 states. While the results were encouraging, there remains a real gap between organizational ambition and readiness. At this point, a majority of the organizations (74%) report that they collect clinical outcome data, but less than half (45%) standardize SDOH screening across all care sites. Although 74% connect annually with community partners, 59% do not measure the direct impact of social needs programs. Most organizations have only recently prioritized health equity in their strategic planning and achieved buy-in from leadership. The most common health equity challenges reported were collecting, analyzing, and validating data and demonstrating impact.

Vizient Vulnerability Index. Encompassing factors such as economic status, education, healthcare access, housing, neighborhood conditions, cleanliness of environment, social environment, and access to transportation, this metric is useful in summarizing data on SDOH at the neighborhood level. It provides context for obstacles faced by patients in accessing healthcare, and quantifies the direct relationship between these obstacles and patient health outcomes.

With the heightened awareness of disparities, SDOH measure development is quickly taking the form of an emerging industry. A growing number of organizations – public, private, for-profit, and not-for-profit – are busy creating metric sets that are not necessarily aligned. It’s beginning to look a lot like the quality and safety “measure mania” we experienced not that long ago.

This leads me to wonder whether we might be exacerbating the problem of “too many measures”. We should have learned our lesson from the quality and safety sphere – if there are too many measures, providers will not report them. Now is the time to be proactive in determining which SDOH measures really matter.

Determining which measures matter goes well beyond knowing what needs to be fixed. It requires thoughtful consideration of how specific data will be used, and what resources will be necessary (e.g., funding, connectivity) to close care gaps. We know that measures alone cannot drive actions, but tying SDOH measure reporting to resource allocation for addressing problems may be part of the solution.

David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health. He is also editor-in-chief of the American Journal of Medical Quality and of Population Health Management.

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