National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 43 Research Studies DisplayedPatel SA, Krasnow M, Long K
Excess 30-day heart failure readmissions and mortality in black patients increases with neighborhood deprivation.
Researchers examined whether neighborhood environment modifies the disparity in 30-day heart failure (HF) readmissions and mortality between Black and White patients in the Southeastern United States. They created a geocoded retrospective cohort of patients hospitalized for acute HF from 2010-2018 within Emory Healthcare. They found that excess 30-day HF readmissions and mortality were present among Black patients in every neighborhood strata and increased with progressive neighborhood socioeconomic deprivation.
AHRQ-funded; HS026081.
Citation: Patel SA, Krasnow M, Long K .
Excess 30-day heart failure readmissions and mortality in black patients increases with neighborhood deprivation.
Circ Heart Fail 2020 Dec;13(12):e007947. doi: 10.1161/circheartfailure.120.007947..
Keywords: Heart Disease and Health, Cardiovascular Conditions, Hospital Readmissions, Racial and Ethnic Minorities, Mortality, Social Determinants of Health, Low-Income, Disparities
Joyce NR, Pfeiffer MR, Zullo AR
Individual and geographic variation in driver's license suspensions: evidence of disparities by race, ethnicity and income.
Using data from the New Jersey Safety Health Outcomes data warehouse 2004-2018, the authors compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension. They found that 91% of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs. They recommended additional work to determine what effect this has for the social and economic well-being of suspended drivers.
AHRQ-funded; HS022998.
Citation: Joyce NR, Pfeiffer MR, Zullo AR .
Individual and geographic variation in driver's license suspensions: evidence of disparities by race, ethnicity and income.
J Transp Health 2020 Dec;19. doi: 10.1016/j.jth.2020.100933..
Keywords: Racial and Ethnic Minorities, Disparities, Low-Income, Vulnerable Populations, Social Determinants of Health
Brewster AL, Fraze TK, Gottlieb LM
The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by US physicians.
The authors studied the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. Their results indicated that implementation of social risk screening was not associated with overall exposure to value-based payment for physician practices. They recommended expanding social risk screening in order to reduce the level of innovative capacity required.
AHRQ-funded; HS024075.
Citation: Brewster AL, Fraze TK, Gottlieb LM .
The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by US physicians.
Milbank Q 2020 Dec;98(4):1114-33. doi: 10.1111/1468-0009.12480..
Keywords: Payment, Social Determinants of Health, Practice Patterns, Vulnerable Populations, Screening, Risk, Nutrition
Pantell MS, Adler-Milstein J, Wang MD
A call for social informatics.
This article discusses the emergence of a new subfield of health informatics, focused on the application of information technologies to capture and apply social data in conjunction with health data to advance individual and population health. Many professional organizations have endorsed screening for social determinants of health (SDOH), and the US Office of the National Coordinator for Health Information Technology has recommended increased capacity of health information technology to integrate and support use of SDOH in clinical settings.
AHRQ-funded; HS026383.
Citation: Pantell MS, Adler-Milstein J, Wang MD .
A call for social informatics.
J Am Med Inform Assoc 2020 Nov;27(11):1798-801. doi: 10.1093/jamia/ocaa175..
Keywords: Health Information Technology (HIT), Social Determinants of Health
Althoff KN, Leifheit KM, Park JN
Opioid-related overdose mortality in the era of fentanyl: monitoring a shifting epidemic by person, place, and time.
Investigators described US trends in opioid-related overdose mortality rates by race, age, urbanicity, and opioid type before and after the emergence of fentanyl. Using the CDC’s WONDER database, they found a disproportionate increase in opioid-related overdose deaths among urban non-Hispanic Black Americans and recommended interventions for this population in order to halt the increase in overdose deaths.
AHRQ-funded; HS000046.
Citation: Althoff KN, Leifheit KM, Park JN .
Opioid-related overdose mortality in the era of fentanyl: monitoring a shifting epidemic by person, place, and time.
Drug Alcohol Depend 2020 Nov 1;216:108321. doi: 10.1016/j.drugalcdep.2020.108321..
Keywords: Opioids, Medication, Substance Abuse, Mortality, Racial and Ethnic Minorities, Social Determinants of Health
Roberts ET, Mehrotra A
Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine.
In this study, the investigators examined disparities in digital access (ie, access at home to technology that enables video telemedicine visits) among Medicare beneficiaries by socioeconomic and demographic characteristics. The investigators concluded that the proportion of beneficiaries who lacked digital access was higher among those with low socioeconomic status, those 85 years or older, and in communities of color.
AHRQ-funded; HS026727.
Citation: Roberts ET, Mehrotra A .
Assessment of disparities in digital access among Medicare beneficiaries and implications for telemedicine.
JAMA Intern Med 2020 Oct;180(10):1386-89. doi: 10.1001/jamainternmed.2020.2666..
Keywords: Elderly, Medicare, Telehealth, Health Information Technology (HIT), Disparities, Access to Care, Social Determinants of Health, Low-Income, Racial and Ethnic Minorities
Vasan A, Morgan JW, Mitra N
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
The purpose of this study was to analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. The investigators concluded that data from three randomized clinical trials across multiple settings showed that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. They indicated that this study was the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.
AHRQ-funded.
Citation: Vasan A, Morgan JW, Mitra N .
Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: a pooled analysis of three clinical trials.
Health Serv Res 2020 Oct;55(Suppl 2):894-901. doi: 10.1111/1475-6773.13321..
Keywords: Hospitalization, Chronic Conditions, Vulnerable Populations, Social Determinants of Health, Community-Based Practice
Whooten RC, Horan C, Cordes J
Evaluating the implementation of a before-school physical activity program: a mixed-methods approach in Massachusetts, 2018.
The aim of this study was to evaluate the implementation of a widely available, before-school, physical activity program in a low-resource, racially/ethnically and socioeconomically diverse, urban school setting to identify adaptations needed for successful implementation. The investigators used a collaborative effort with stakeholders to implement the Build Our Kids' Success (BOKS) program in 3 schools in Revere, Massachusetts.
AHRQ-funded; HS000063.
Citation: Whooten RC, Horan C, Cordes J .
Evaluating the implementation of a before-school physical activity program: a mixed-methods approach in Massachusetts, 2018.
Prev Chronic Dis 2020 Oct 1;17:E116. doi: 10.5888/pcd17.190445..
Keywords: Children/Adolescents, Education, Implementation, Health Promotion, Prevention, Lifestyle Changes, Social Determinants of Health
Davidson KW, Kemper AR, Doubeni CA
AHRQ Author: Mills J, Borsky A
Developing primary care-based recommendations for social determinants of health: methods of the U.S. Preventive Services Task Force.
This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations. By reviewing the evidence on the effects of screening and interventions on social determinants relevant to primary care, the USPSTF will continue to be able to provide recommendations on clinical preventive services to improve the health of all Americans.
AHRQ-authored.
Citation: Davidson KW, Kemper AR, Doubeni CA .
Developing primary care-based recommendations for social determinants of health: methods of the U.S. Preventive Services Task Force.
Ann Intern Med 2020 Sep 15;173(6):461-67. doi: 10.7326/m20-0730..
Keywords: U.S. Preventive Services Task Force (USPSTF), Primary Care, Social Determinants of Health, Evidence-Based Practice, Guidelines, Screening, Prevention
Oates GR, Baker E, Rowe SM
Tobacco smoke exposure and socioeconomic factors are independent predictors of pulmonary decline in pediatric cystic fibrosis.
This longitudinal study evaluates the effects of tobacco smoke exposure and socioeconomic factors on pulmonary decline in pediatric cystic fibrosis (CF). Data from the CF Foundation Patient Registration was obtained for patients who were 6-18 years old at the end of 2016. Lung function measures (ppFEV(1)) for 10,895 individuals was calculated at each attained age. At age 6, lung function was 4.7% lower among smoke-exposed children than among unexposed with this deficit continuing through age 18. Smoke exposure and socioeconomic factors had independent, additive associations with lung function. Factors that declined ppFEV(1) include smoke exposure (2.4%), lower paternal education (4.9%), public insurance (0.3%), and increased 0.2% with each $10,000 annual household income.
AHRQ-funded; HS023009.
Citation: Oates GR, Baker E, Rowe SM .
Tobacco smoke exposure and socioeconomic factors are independent predictors of pulmonary decline in pediatric cystic fibrosis.
J Cyst Fibros 2020 Sep;19(5):783-90. doi: 10.1016/j.jcf.2020.02.004..
Keywords: Children/Adolescents, Respiratory Conditions, Tobacco Use, Social Determinants of Health, Risk
Bolstad CJ, Moak R, Brown CJ
Neighborhood disadvantage is associated with depressive symptoms but not depression diagnosis in older adults.
This study tested how neighborhood disadvantage (ND) relates to depressive symptomology and diagnosis to assess for neighborhood disparities in mental health care cross-sectionally. Using data from the University of Alabama at Birmingham Study of Aging, the investigators found living in the high and mid-ND tertiles to be associated with depressive symptomology, yet ND had no significant relation to depression diagnosis. They concluded that older adults living in high and mid-disadvantaged neighborhoods may be more likely to experience depressive symptomology but not receive a diagnosis, indicating a possible disparity in mental health care.
AHRQ-funded; HS013852.
Citation: Bolstad CJ, Moak R, Brown CJ .
Neighborhood disadvantage is associated with depressive symptoms but not depression diagnosis in older adults.
Int J Environ Res Public Health 2020 Aug 8;17(16). doi: 10.3390/ijerph17165745..
Keywords: Elderly, Depression, Behavioral Health, Diagnostic Safety and Quality, Disparities, Social Determinants of Health
Atkins M, Castro I, Sharifi M
Unmet social needs and adherence to pediatric weight management interventions: Massachusetts, 2017-2019.
This study examined the effects of housing insecurity and unmet social needs on adherence to pediatric weight management intervention (PWMI) programs. The authors used data from children enrolled in a 2017-2019 comparative effectiveness trial for 2 high-intensive PWMIs in Massachusetts. Families with housing security had higher contact hours with the program than families without. Children with 3 to 4 unmet social needs (parental stress, parental depression, food insecurity, and housing insecurity) also attended less hours of the program than those without.
AHRQ-funded; HS024332.
Citation: Atkins M, Castro I, Sharifi M .
Unmet social needs and adherence to pediatric weight management interventions: Massachusetts, 2017-2019.
Am J Public Health 2020 Jul;110(S2):S251-s57. doi: 10.2105/ajph.2020.305772..
Keywords: Children/Adolescents, Obesity: Weight Management, Obesity, Patient Adherence/Compliance, Social Determinants of Health, Family Health and History
Fiori KP, Heller CG, Rehm CD
Unmet social needs and no-show visits in primary care in a US Northeastern urban health system, 2018-2019.
This study used results from a 10-item social needs screener conducted across 19 primary care practices in Bronx County, New York to determine reasons for no-show appointments between April 2018 and July 2019. They examined the association between unmet needs and a 2-year history of missed appointments from 41,637 patients. Overall, the no-show appointment rate was 26.6%. Patients with 1 or more unmet social needs had a significantly higher no-show proportion (31.5%) than those without (26.3%). The strongest association with no-shows was with transportation problems.
AHRQ-funded; HS026396.
Citation: Fiori KP, Heller CG, Rehm CD .
Unmet social needs and no-show visits in primary care in a US Northeastern urban health system, 2018-2019.
Am J Public Health 2020 Jul;110(S2):S242-s50. doi: 10.2105/ajph.2020.305717..
Keywords: Urban Health, Primary Care, Access to Care, Social Determinants of Health
Wallace AS, Luther B, Guo JW
Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018.
Emergency departments see a disproportionate share of low-income and uninsured patients. In this study, the investigators developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data. They leveraged an academic-community partnership to develop a social needs screening tool and referral process.
AHRQ-funded; HS026505.
Citation: Wallace AS, Luther B, Guo JW .
Implementing a social determinants screening and referral infrastructure during routine emergency department visits, Utah, 2017-2018.
Prev Chronic Dis 2020 Jun 18;17:E45. doi: 10.5888/pcd17.190339..
Keywords: Social Determinants of Health, Emergency Department, Screening, Community-Based Practice, Community Partnerships
Jannat-Khah DP, Khodneva Y, Bryant K
Depressive symptoms do not discriminate: racial and economic influences between time-varying depressive symptoms and mortality among REGARDS participants.
This study examined whether time-varying depressive symptoms (TVDS) predict mortality and if racial and income differences moderate the association in a large cohort. The cohort from the REGARDS study was used to look at that determination. The REGARDS study used community-dwelling U.S. adults aged 45 years or older. They found that there was similar and statistically significant differences with white, black, and low-income ($35,000 or less) participants for the association between TVDS and mortality. High-income participants were found to have a lower hazard.
AHRQ-funded; HS025198.
Citation: Jannat-Khah DP, Khodneva Y, Bryant K .
Depressive symptoms do not discriminate: racial and economic influences between time-varying depressive symptoms and mortality among REGARDS participants.
Ann Epidemiol 2020 Jun;46:31-40.e2. doi: 10.1016/j.annepidem.2020.04.004..
Keywords: Depression, Behavioral Health, Racial and Ethnic Minorities, Cardiovascular Conditions, Cancer, Low-Income, Social Determinants of Health, Mortality
Fiori KP, Rehm CD, Sanderson D
Integrating social needs screening and community health workers in primary care: the community linkage to care program.
This study used logistic regression to identify factors associated with successful social service uptake in an urban pediatric practice. Out of 4948 households screened for social needs from December 2017 to November 2018, 20% self-reported at least one factor. Only 43% of the 287 households with unmet needs reported social service uptake. Greater than 4 outreach encounters were significantly associated with successful referrals. This study suggests the need for additional research and an opportunity for further program optimization.
AHRQ-funded; HS026396.
Citation: Fiori KP, Rehm CD, Sanderson D .
Integrating social needs screening and community health workers in primary care: the community linkage to care program.
Clin Pediatr 2020 Jun;59(6):547-56. doi: 10.1177/0009922820908589..
Keywords: Children/Adolescents, Community-Based Practice, Primary Care, Social Determinants of Health, Implementation, Low-Income
Basu J
AHRQ Author: Basu J
Multilevel risk factors for hospital readmission among patients with opioid use disorder in selected US States: role of socioeconomic characteristics of patients and their community.
This study examined the association of socioeconomic characteristics of individuals hospitalized with a principal diagnosis of opioid use disorder and their all-cause 30-day readmission risks. Discharge data from the 2014 HCUP Survey was used and was linked to community and hospital characteristics using data from HRSA and the American Hospital Association. Medicare is associated with the highest readmission risk followed by Medicaid covered patients. Self-pay or covered by other payers had a similar risk to private insurance coverage. Urban patients also had a higher readmission rate than rural patients.
AHRQ-authored.
Citation: Basu J .
Multilevel risk factors for hospital readmission among patients with opioid use disorder in selected US States: role of socioeconomic characteristics of patients and their community.
Health Serv Res Manag Epidemiol 2020 Jan-Dec;7:2333392820904240. doi: 10.1177/2333392820904240..
Keywords: Healthcare Cost and Utilization Project (HCUP), Opioids, Medication, Substance Abuse, Hospital Readmissions, Hospitals, Social Determinants of Health
Lee JT, Polsky D, Fitzsimmons R
Proportion of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining accountable care organizations.
The purpose of this study was to test for changes in the percentage of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining an accountable care organization (ACO). This cohort study’s subjects consisted of a 15% random sample of Medicare fee-for-service beneficiaries attributed to physician groups. ACO file were used to determine Medicare Shared Savings Program (MSSP) participation. No changes were found in the proportions of vulnerable patients cared for by ACO-participating physician groups after joining an ACO compared with changes among nonparticipating groups.
AHRQ-funded; HS025184.
Citation: Lee JT, Polsky D, Fitzsimmons R .
Proportion of racial minority patients and patients with low socioeconomic status cared for by physician groups after joining accountable care organizations.
JAMA Netw Open 2020 May;3():e204439. doi: 10.1001/jamanetworkopen.2020.4439.
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Keywords: Social Determinants of Health, Racial and Ethnic Minorities, Medicare
Cohen DJ, Wyte-Lake T, Dorr DA
Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs.
The authors sought to identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs, and to propose principles for redesigning electronic health records (EHR) to address these needs. They concluded that developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. They recommended that the identified information needs and design principles inform developers and implementers working in community health centers and other settings where complex patients receive care.
AHRQ-funded; HS023324.
Citation: Cohen DJ, Wyte-Lake T, Dorr DA .
Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs.
J Am Med Inform Assoc 2020 May;27(5):690-99. doi: 10.1093/jamia/ocaa010..
Keywords: Healthcare Delivery, Teams, Electronic Health Records (EHRs), Health Information Technology (HIT), Social Determinants of Health, Community-Based Practice, Primary Care
Goto T, Yoshida K, Faridi MK
Contribution of social factors to readmissions within 30 days after hospitalization for COPD exacerbation.
This study examined whether adding social factors improved the predictive ability for 30-day hospital readmissions for COPD. Social factors include educational level and marital status. Out of 905 hospitalizations identified in the Medicare Current Beneficiary Survey from 2006 through 2012, 18.5% were readmitted within 30 days. The optimized model including social factors for prediction improved for early readmissions but not for late readmissions.
AHRQ-funded; HS023305.
Citation: Goto T, Yoshida K, Faridi MK .
Contribution of social factors to readmissions within 30 days after hospitalization for COPD exacerbation.
BMC Pulm Med 2020 Apr 29;20(1):107. doi: 10.1186/s12890-020-1136-8..
Keywords: Respiratory Conditions, Hospital Readmissions, Hospitalization, Social Determinants of Health, Chronic Conditions
Ornelas IJ, Yamanis TJ, Ruiz RA
The health of undocumented Latinx immigrants: what we know and future directions.
This review article summarizes the limited but growing literature on the health of undocumented Latinx immigrations and how exposure to trauma, immigration enforcement, changes to social networks, and discrimination negatively affect their mental and physical health. The authors discuss how policies and social ties can promote their health. They focus on areas of concern and recommend how future research should be conducted.
AHRQ-funded; HS013853.
Citation: Ornelas IJ, Yamanis TJ, Ruiz RA .
The health of undocumented Latinx immigrants: what we know and future directions.
Annu Rev Public Health 2020 Apr 2;41:289-308. doi: 10.1146/annurev-publhealth-040119-094211..
Keywords: Racial and Ethnic Minorities, Vulnerable Populations, Social Determinants of Health, Policy
Chen DW, Reyes-Gastelum D, Wallner LP
Disparities in risk perception of thyroid cancer recurrence and death.
The authors studied risk perception among survivors of thyroid cancer. Patients diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries were surveyed and an analytic cohort defined by a 5% or greater risk of disease recurrence and mortality. The authors found that less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life.
AHRQ-funded; HS024512.
Citation: Chen DW, Reyes-Gastelum D, Wallner LP .
Disparities in risk perception of thyroid cancer recurrence and death.
Cancer 2020 Apr 1;126(7):1512-21. doi: 10.1002/cncr.32670..
Keywords: Disparities, Cancer, Risk, Quality of Life, Social Determinants of Health, Racial and Ethnic Minorities
Fahrenbach J, Chin MH, Huang ES
Neighborhood disadvantage and hospital quality ratings in the Medicare Hospital Compare Program.
This study examined the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program. Results showed that lower hospital summary scores were associated with caring for neighborhoods with higher social risk. Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups and smallest in the safety, efficiency, and effectiveness of care groups. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.
AHRQ-funded; HS023007.
Citation: Fahrenbach J, Chin MH, Huang ES .
Neighborhood disadvantage and hospital quality ratings in the Medicare Hospital Compare Program.
Med Care 2020 Apr;58(4):376-83. doi: 10.1097/mlr.0000000000001283..
Keywords: Quality of Care, Hospitals, Medicare, Quality Indicators (QIs), Patient Experience, Social Determinants of Health
Heller CG, Parsons AS, Chambers EC
Social risks among primary care patients in a large urban health system.
The objective of this study was to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system. Participants across nineteen ambulatory sites in the Bronx, New York, completed a 10-item screener. Findings showed that there were important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.
AHRQ-funded; HS026396.
Citation: Heller CG, Parsons AS, Chambers EC .
Social risks among primary care patients in a large urban health system.
Am J Prev Med 2020 Apr;58(4):514-25. doi: 10.1016/j.amepre.2019.11.011..
Keywords: Social Determinants of Health, Primary Care, Urban Health, Risk, Vulnerable Populations
Grafova IB, Monheit AC, Kumar R
How do changes in income, employment and health insurance affect family mental health spending?
This study used eight two-year panels from the MEPS data for 2004 to 2012 to examine the effect of economic shocks on mental health spending by families with children. Researchers wanted to determine whether the greatest impact on mental health spending comes from income, employment, or health insurance shocks. They used two-part expenditure models to estimate that employment losses are positively related to an increase in total family mental health expenditures. But no link was found between economic shocks and mental health spending on fathers.
AHRQ-funded; HS024053.
Citation: Grafova IB, Monheit AC, Kumar R .
How do changes in income, employment and health insurance affect family mental health spending?
Rev Econ Househ 2020 Mar;18(1:239-63. doi: 10.1007/s11150-018-9436-y.
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Keywords: Medical Expenditure Panel Survey (MEPS), Healthcare Costs, Behavioral Health, Social Determinants of Health, Health Insurance