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Assessing Patient and Community-Level Social Factors; The Synergistic Effect of Social Needs and Social Determinants of Health on Healthcare Utilization at a Multilevel Academic Healthcare System

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Abstract

We investigated the role of both individual-level social needs and community-level social determinants of health (SDOH) in explaining emergency department (ED) utilization rates. We also assessed the potential synergies between the two levels of analysis and their combined effect on patterns of ED visits. We extracted electronic health record (EHR) data between July 2016 and June 2020 for 1,308,598 unique Maryland residents who received care at Johns Hopkins Health System, of which 28,937 (2.2%) patients had at least one documented social need. There was a negative correlation between median household income in a neighborhood with having a social need such as financial resource strain, food insecurity, and residential instability (correlation coefficient: -0.05, -0.01, and − 0.06, p = 0, respectively). In a multilevel model with random effects after adjusting for other factors, living in a more disadvantaged neighborhood was found to be significantly associated with ED utilization statewide and within Baltimore City (OR: 1.005, 95% CI: 1.003–1.007 and 1.020, 95% CI: 1.017–1.022, respectively). However, individual-level social needs appeared to enhance the statewide effect of living in a more disadvantaged neighborhood with the OR for the interaction term between social needs and SDOH being larger, and more positive, than SDOH alone (OR: 1.012, 95% CI: 1.011–1.014). No such moderation was found in Baltimore City. To our knowledge, this study is one of the first attempts by a major academic healthcare system to assess the combined impact of patient-level social needs in association with community-level SDOH on healthcare utilization and can serve as a baseline for future studies using EHR data linked to population-level data to assess such synergistic association.

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Data Availability and code availability

Due to privacy and security issues neither identifiable nor de-identified patient data can be shared. In addition, the use of underlying datasets is governed under the terms of their stakeholder agreements – which do not permit such data sharing beyond this research. JHHS-EHR contains the data of 5 + million patients. However, as most healthcare systems have similar databases (e.g., hospital discharges and health information exchange data), the methods will be shared with other researchers upon request.

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Funding

This publication was made possible by the Johns Hopkins ICTR, which is funded in part by grant number UL1 TR001079 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, NCATS, or NIH.

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Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Elham Hatef

  2. Center for Population Health IT, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 502, Baltimore, MD, 21205, USA

    Elham Hatef, Christopher Kitchen, Chintan Pandya & Hadi Kharrazi

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  1. Elham Hatef
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  2. Christopher Kitchen
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Contributions

All authors contributed significantly to the study and writing of the paper. All authors reviewed the final paper and provided comments as deemed necessary. EH supervised the selection of social domains, related ICD codes, and analysis process. CK performed the data analysis and interpretation of the results. CP supported EH in the development of the analysis plan and interpretation of the results. HK was the principal investigator of the study, designed the overall scope and goals of the study, and supervised the day-to-day operations of the study.

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Correspondence to Elham Hatef.

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The Institutional Review Board of Johns Hopkins Bloomberg School of Public Health approved this study.

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Hatef, E., Kitchen, C., Pandya, C. et al. Assessing Patient and Community-Level Social Factors; The Synergistic Effect of Social Needs and Social Determinants of Health on Healthcare Utilization at a Multilevel Academic Healthcare System. J Med Syst 47, 95 (2023). https://doi.org/10.1007/s10916-023-01990-9

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