Interventions for Redressing Disparities Related to Social Determinants of Health in Surgery

Background

The United States (US) Department of Health and Human Services defines social determinants of health (SDOH) as “the conditions in environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH include housing, transportation, education, literacy, employment, environment, discrimination, and violence domains within which individuals' demographic characteristics (e.g., race, country of origin) as well as provider-level and systemic biases contribute to differential access to resources and propagation of health disparities.

While SDOH have gained attention in research, quality improvement, and patient care in recent years, effectively identifying and intervening on barriers to equitable resource allocation and opportunity related to various SDOH remains challenging. In this chapter, we will discuss the current state of data collection on SDOH and address patient-, provider-, and system-level interventions reported in the literature with a focus on surgical care. We conclude the chapter with theoretical frameworks to guide development and implementation of equity-focused interventions.

Data Collection

To address health disparities in surgery and healthcare at large, we must first understand the state of social drivers, leading to downstream disparities in clinical outcomes and care quality. It is essential to maintain an up-to-date understanding of these drivers to develop meaningful research questions and subsequent interventions.

The “history and physical” is considered the backbone of a patient's medical record, the documentation that summarizes the clinical and social circumstances that led to an individual presenting for clinical care. However, there is significant provider variation with regard to the accuracy and completeness of clinical documentation. For many providers, it is uncommon to complete a “social history” beyond tobacco, alcohol, or recreational drug use, and few ask about housing and food security or social isolation at clinic visits. ^, Even if electronic health record (EHR) systems have mechanisms for documenting health literacy, it is unclear how frequently this is recorded by clinicians or used to provide appropriately tailored documentation in after-visit summaries including perioperative instructions. These type of data can theoretically be collected by outpatient primary care physicians, specialty care physicians, and clinic staff in the EHR or even by hand if time or resources are limited. However, temporal and financial pressures often prevent histories being taken that might reveal SDOH-related challenges and opportunity to address specific barriers to care.

If SDOH-related data collection occurs at all, it is typically event-, procedure-, or screen-triggered and often without mechanisms for regular updating (e.g., smoking history often collected at initial establishment of care, but not at subsequent visits). While some patients may choose to update these elements of their personal and social history using patient-facing EHR applications such as Epic's MyChart, many patients with limited technological access, bandwidth, or literacy may not. Furthermore, factors such as incarceration or residence in an assisted living facility may limit patient access to reporting mechanisms, and some SDOH such as environmental exposures may be unknown to patients themselves.

Several interventions can improve SDOH data collection processes. These include having standardized tools for SDOH data collection; dedicated, nonprovider individuals to collect SDOH-related data outside the clinical encounter; ensuring multiple modalities (e.g., patient portal, text message, paper and pencil) and opportunities (e.g., at home, in the clinic waiting room); and ensuring that both patients and providers feel the data are worth collecting by demonstrating real-time application and providing tangible assistance in response to patient-reported data. In oncology, surgeons are often the first providers patients see after a new diagnosis of cancer, thus during or even prior to the initial surgical oncologic evaluation representing an important opportunity to capture and intervene upon these data.

Finally, compliance with recommendations from government agencies and payers including the Centers from Medicare and Medicaid Services (CMS) may also encourage system-level commitment to standardizing SDOH data collection. ^, “Z codes” (i.e., Z55-Z65) are a set of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) psychosocial risk and SDOH-related codes that can be used by providers including physicians and advanced practice providers as well as social workers to facilitate social history completion ( Fig. 15.1A–B ). Given increased promotion of Z code utilization by CMS and potential linkage of Z code usage to value-based payments, more widely adopted and consistent documentation of SDOH-related data may not only be desirable with regard to promoting health equity but also for the sake of these systems' own financial well-being.