Food insecurity, social needs, and smoking status among patients in a county hospital system.

Tobacco use in the U.S. is increasingly concentrated among populations with socioeconomic disadvantages such as food insecurity. Building on prior studies showing that food insecurity increases odds of cigarette smoking, the current study sought to examine how food insecurity and other social needs, particularly financial strain, transportation barriers, and housing/utility insecurity, were associated with smoking status among adult patients seen in a county hospital system. We analyzed data from the electronic health record of patients from The MetroHealth System (Cleveland, Ohio, USA), covering a two-year period since implementation of social determinants of health assessments (2019-2021; N = 45,151 patients). Logistic regression analyses were used to examine associations with smoking status. Compared to the overall smoking prevalence (21 %), smoking was higher among patients screening for transportation barriers (41 %), financial strain (39 %), food insecurity (34 %), and housing/utility insecurity (27 %). Each of these social needs was independently associated with increased odds of current smoking (all p < 0.05). Smoking prevalence increased sequentially as the number of social needs increased; with each addition of a social need, there was a dose-response association with higher odds of current smoking (adjusted ORs ranged from 1.56 to 3.76, all p < 0.001), and current smoking specifically among ever smoking patients (adjusted ORs ranged from 1.39 to 3.01, all p < 0.001). There was substantial overlap among several social needs and smoking status. Alongside improving access to evidence-based cessation treatments and services, the findings raise the possibility that addressing social needs might reduce barriers to quitting and thereby reduce tobacco use disparities.

A Framework for Evaluating Social Determinants of Health Screening and Referrals for Assistance.

INTRODUCTION/OBJECTIVES: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. We developed a framework based on sequential steps to evaluate this process. METHODS: We reviewed efforts by The MetroHealth System in Cleveland, Ohio and identified 6 sequential steps: patient screened, has social needs, consents to referral to a service organization, referral placed, referral accepted, and referral outcome. Referral outcomes were categorized as resolved (organization provided requested service or patient self-resolved problem), or unresolved (patient unable to be contacted or declined assistance). We then determined the numbers of patients with food insecurity who completed each step, how completion differed by patient characteristics and service organization, and reasons for failure to complete specific steps. RESULTS: We used the framework to evaluate screening and assistance steps among 5741 patients who attended a COVID-19 vaccine clinic from February 15-March 31, 2021 and were followed through April 30, 2021. The percentage of patients who completed each step ranged from 17-98%. Step completion differed by patient age, patient race, and clinic. Of 360 referrals accepted by community organizations, 98 (27%) were resolved. The most common reasons for unresolved referrals were inability of service organization to contact patients (151), no reason stated (71), and patients declined service (30). CONCLUSIONS: A framework based on sequential steps may be used to evaluate social determinants of health screening and assistance programs. Further work is needed to address reasons for failure to complete steps, to include patient perspectives, and to determine long-term outcomes.

Mortality and length of stay in a veterans affairs hospital and private sector hospitals serving a common market.

OBJECTIVE: To compare severity-adjusted in-hospital mortality and length of stay (LOS) in a Veterans Administration (VA) hospital and private sector hospitals serving the same health care market. DESIGN: Retrospective cohort study. SETTING: A large VA hospital and 27 private sector hospitals in the same metropolitan area. PATIENTS: Consecutive VA (N = 1,960) and private sector (N = 157,147) admissions in 1994 to 1995 with 9 high-volume diagnoses. MEASUREMENTS: Severity of illness was measured using validated multivariable models that were based on data abstracted from medical records. Outcomes were adjusted for severity and compared in VA and private sector patients using multiple logistic or linear regression analysis. MAIN RESULTS: Unadjusted mortality was similar in VA and private sector patients (5.0% vs 5.6%, respectively; P =.26), although mean LOS was longer in VA patients (12.7 vs 7.0 days; P <.001). Adjusting for severity, the odds of death in VA patients was similar (odds ratio [OR] 1.07; 95% confidence interval [95% CI], 0.74 to 1.54; P =.73). However, a larger proportion of deaths in VA patients occurred later during hospitalization (P <.001), and the odds of death in VA patients were actually lower (P <.05) in analyses limited to deaths during the first 7 (OR, 0.56) or 14 (OR, 0.63) days. Adjusted LOS was longer (P <.001) in VA patients for all 9 diagnoses. CONCLUSIONS: If the current findings generalizable to other markets, hospital mortality, a widely used performance measure, may be similar or lower in VA and private sector hospitals serving the same markets. The longer LOS of VA patients may reflect differences in practice patterns and may be an important source of bias in comparisons of VA and private sector hospitals.