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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
101 to 125 of 355 Research Studies DisplayedDavidson 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
Fashaw S, Chisholm L, Mor V
Inappropriate antipsychotic use: the impact of nursing home socioeconomic and racial composition.
Researchers examined how nursing home characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics, using national data from Long-Term Care: Facts on Care. They found an overall decline in the use of antipsychotics. Although findings indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among nursing homes. They recommended that policy interventions focusing on reimbursement be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant nursing homes.
ARHQ-funded; HS000011.
Citation: Fashaw S, Chisholm L, Mor V .
Inappropriate antipsychotic use: the impact of nursing home socioeconomic and racial composition.
J Am Geriatr Soc 2020 Mar;68(3):630-36. doi: 10.1111/jgs.16316..
Keywords: Nursing Homes, Long-Term Care, Elderly, Medication, Medication: Safety, Social Determinants of Health, Disparities, Racial and Ethnic Minorities
Murray GF, Rodriguez HP, Lewis VA
Upstream with a small paddle: how ACOs are working against the current to meet patients' social needs.
This study’s goal was to understand how health care providers with strong motivation and commitment fared at addressing patients' social needs. Researchers found that the 22 accountable care organizations studied were frequently lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between accountable care organizations and community-based organizations were only in the early stages of development. The researchers concluded that policies that could facilitate the integration of social determinants included providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.
AHRQ-funded; HS024792.
Citation: Murray GF, Rodriguez HP, Lewis VA .
Upstream with a small paddle: how ACOs are working against the current to meet patients' social needs.
Health Aff 2020 Feb;39(2):199-206. doi: 10.1377/hlthaff.2019.01266..
Keywords: Social Determinants of Health, Health Services Research (HSR)
Ellis RJ, Schlick CJR, Feinglass J
Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?
This study examined hospital variation in cancer patients who did not receive recommended chemotherapy. Patients with breast, colon, and lung cancers who did not receive chemotherapy from 2000 to 2015 were identified from the National Cancer Database. A total of 183,148 patients at 1281 hospitals were included. For breast cancer, 3.5% of patients failed to receive recommended chemotherapy, and 6.6% with colon, and 10.7% with lung cancer. Sociodemographic factors showed that patients were less likely to receive chemotherapy if they were uninsured or on Medicaid, as were non-Hispanic black patients with both breast and colon cancer. There was also significant hospital variation with failure to administer as high as 21.8% for breast, 40.2% for colon, and 40.0% for lung cancer.
AHRQ-funded; HS000078; HS026385.
Citation: Ellis RJ, Schlick CJR, Feinglass J .
Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?
BMJ Qual Saf 2020 Feb;29(2):103-12. doi: 10.1136/bmjqs-2019-009742..
Keywords: Treatments, Cancer, Healthcare Delivery, Access to Care, Healthcare Utilization, Social Determinants of Health, Vulnerable Populations, Uninsured, Hospitals, Quality of Care
Garcia RM, Prabhakaran S, Richards CT
Race, socioeconomic status, and gastrostomy after spontaneous intracerebral hemorrhage.
This study sought to determine if socioeconomic status among minorities indicates higher or lower use of a gastrostomy tube for patients with intracerebral hemorrhage. Patients at a single center were enrolled in an observational cohort study from 2010 to 2017. Zip codes were used to impute socioeconomic status. Of the 512 patients, 18.2% underwent gastrostomy tube placement. Blacks had the highest percentage of placement and Whites the lowest. Only with Hispanics was socioeconomic index independently associated with gastrostomy placement and the lower the income, the less likelihood of gastrostomy use.
AHRQ-funded; HS023437.
Citation: Garcia RM, Prabhakaran S, Richards CT .
Race, socioeconomic status, and gastrostomy after spontaneous intracerebral hemorrhage.
J Stroke Cerebrovasc Dis 2020 Feb;29(2):104567. doi: 10.1016/j.jstrokecerebrovasdis.2019.104567.
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Keywords: Social Determinants of Health, Racial and Ethnic Minorities, Surgery, Disparities
Klawetter S, McNitt C, Hoffman JA
Perinatal depression in low-income women: a literature review and innovative screening approach.
This paper is a literature review of perinatal depression prevalence, consequences, and screening among low-income women and women of color. The Warm Connections program has an innovative perinatal depression screening protocol and was used with WIC participants. The literature showed mixed findings of perinatal prevalence among low-income women and women of color. There were lower perinatal depression rates in the Warm Connections program in studies using less specific perinatal depression screening instruments with similar samples.
AHRQ-funded; HS026370.
Citation: Klawetter S, McNitt C, Hoffman JA .
Perinatal depression in low-income women: a literature review and innovative screening approach.
Curr Psychiatry Rep 2020 Jan 7;22(1):1. doi: 10.1007/s11920-019-1126-9.
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Keywords: Depression, Pregnancy, Women, Low-Income, Social Determinants of Health, Screening, Behavioral Health, Maternal Care, Disparities, Diagnostic Safety and Quality
French DD, Wang A, Prager AJ
Association of the Robert Wood Johnson Foundations' social determinants of health and Medicare ocular hospitalizations: a cross sectional data analysis.
The purpose of this paper was to determine whether social determinants of health are associated with ocular hospitalizations. Results showed that, compared to an all-condition hospitalized population, ocular hospitalizations tended to have small, yet statistically significant, associations with health behaviors, socioeconomic, and physical environment factors. Further research is recommended on how these variables affect ocular health relative to all-cause hospitalizations.
AHRQ-funded; HS000078; HS000084.
Citation: French DD, Wang A, Prager AJ .
Association of the Robert Wood Johnson Foundations' social determinants of health and Medicare ocular hospitalizations: a cross sectional data analysis.
Ophthalmol Ther 2019 Dec;8(4):611-22. doi: 10.1007/s40123-019-00220-1..
Keywords: Social Determinants of Health, Eye Disease and Health, Hospitalization, Medicare
McMurtry CL, Findling MG, Casey LS
Discrimination in the United States: experiences of Asian Americans.
This study examined the prevalence of racial discrimination among Asian Americans and its impact on health outcomes. A nationally representative, probability-based telephone survey was conducted comparing 500 Asian and 902 white US adults from January to April 2017. Thirteen percent of Asians reported discrimination in healthcare encounters, and at least one in four experienced discrimination in employment, housing, and experienced microaggressions (35%) or racial slurs (32%). This resulted in Asians having higher odds than whites of reporting avoiding health care due to discrimination concerns.
AHRQ-funded; HS000055.
Citation: McMurtry CL, Findling MG, Casey LS .
Discrimination in the United States: experiences of Asian Americans.
Health Serv Res 2019 Dec;54(Suppl2):1419-30. doi: 10.1111/1475-6773.13225..
Keywords: Racial and Ethnic Minorities, Disparities, Social Determinants of Health, Patient Experience
Fichtenberg CM, Alley DE, Mistry KB
AHRQ Author: Mistry KB
Improving social needs intervention research: key questions for advancing the field.
This paper summarizes emerging evidence and identifies key areas where more research is needed to advance implementation and policy development. Gaps exist in terms of comparative effectiveness and cost effectiveness of social needs intervention approaches. Increased understanding of mechanisms of action to maximize practitioners' ability to tailor interventions would be a benefit. More research is recommended to guard against unintended consequences and ensure these interventions reduce health inequities. Implementation science research should identify supports and incentives for adoption of effective interventions. Focusing both public and private research efforts on these evidence gaps can help advance identification of interventions that maximize both health equity and healthcare value.
AHRQ-authored; AHRQ-funded; HS026664.
Citation: Fichtenberg CM, Alley DE, Mistry KB .
Improving social needs intervention research: key questions for advancing the field.
Am J Prev Med 2019 Dec;57(6s1):S47-s54. doi: 10.1016/j.amepre.2019.07.018..
Keywords: Evidence-Based Practice, Patient-Centered Outcomes Research, Social Determinants of Health