Knowing Neighborhoods' Specific Needs a Step Toward Improved Care
Commentary — February 2018
Tex Med. 2018;114(2):8–10.
By Vincent Fonseca, MD
If we are to improve the health of all Texans ― that is, support population health improvement at the state level ― we must address health disparities.
Health disparities are preventable differences in the burden of disease, injury, and violence, or in opportunities to achieve optimal health that are experienced by certain populations. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual's ability to achieve good health.
To address health disparities, we must go upstream and address the real causes of the disparities (e.g., disparities in diabetes outcomes related to differences in lifestyle). Even more upstream are the root causes of disparities, the social determinants of health.
We find health disparities almost everywhere we have data to examine. We often see disparities by race/ethnicity, as that is often captured in health-related data systems. Unfortunately, in Texas and the rest of the country, race/ethnicity isn't the real cause of the disparity but is a proxy for the root causes: food insecurity; housing instability; transportation problems; poverty; low educational attainment; unemployment, unsafe jobs, or unsafe neighborhoods (violence or pollution); poor access to affordable, high-quality health services; and others. These are the social determinants of health ― the conditions in which people are born, grow, live, work, and age.
For example, one of the most basic concepts in health is self-perceived health status. Self-perceived health status can be categorized as excellent, very good, good, fair, or poor. In the 2014 Texas Behavioral Risk Factor Surveillance System (BRFSS), 15 percent of non-Hispanic whites had fair/poor health compared with 25 percent of Hispanics. Hispanics' rate of fair/poor health was 67 percent higher than whites.
Neighborhoods with concentrated poverty and concentrated low educational attainment ― two of the root causes of health disparities ― also are neighborhoods with loose dogs. They also are neighborhoods with low-performing schools and neighborhoods where segregation and health disparities exist. In a sense, if physicians and providers don't understand the profound impact of the social determinants of health, they might be surprised that loose dogs are somehow related to poor blood pressure control.
Primary care providers see the impact every day in patients with chronic conditions. Chronic condition self-management is the key to improved outcomes individually and at the population level. However, it is more difficult to effectively self-manage ― whether it's eating healthier, getting more physical activity, or adhering to medication schedules ― when patients also are struggling with food insecurity, housing insecurity, keeping the utilities on, or dangerous neighborhoods.
The local health information exchange in Bexar County, HASA, categorized glucose control in patients with diabetes by ZIP codes. They found that the proportion of patients with poor control (≥ 9 percent) was higher in ZIP codes with concentrated poverty and concentrated low educational attainment (high social determinant risk).
While health care professionals may be aware of their patients' struggles, they probably haven't had aggregated patient outcomes stratified by factors such as social determinant risk. Most of the quality measurement systems don't address social determinants of health and have just one standard for recognition set of clinical quality criteria (e.g., the Merit-Based Incentive Payment System [MIPS]), whether patients are from mainly high-income or mainly low-income households. However, the MIPS bonus or penalties could adversely affect providers who care for patients for high social determinant risk.
Health care professionals might find it useful to view their area's census tracts with high social determinant risk, known as "vulnerable populations." They should then review the Centers for Disease Control and Prevention (CDC) 500 Cities project, which has estimates down to the census-tract level for the largest 500 cities in the United States ― including 47 in Texas ― based on the BRFSS. Although the CDC site provides information on adults only, details on many topics are available: 13 health outcomes, 10 prevention, and five unhealthy behavior topics. Knowing which census tracts are in greatest need will help providers and communities meet those needs.
While difficult and new, some national efforts connect individual patients and households to specific community-based social service support. An American Academy of Pediatrics project screens for food insecurity and then coordinates community services for those families. The Centers for Medicare & Medicaid Services has an Accountable Health Communities pilot project that screens for five social determinants and coordinates community services where they provide funding to help providers do this extra work.
Until we work together with community-based organizations that provide services to address the social determinants of health, we will not make the desired improvements in population health.
Vincent Fonseca, MD, is an associate professor of preventive medicine at the University of the Incarnate Word School of Osteopathic Medicine. He also is the medical adviser at Healthcare Access San Antonio, the community health information exchange for the San Antonio area with more than 3 million unique patients; the health adviser for San Antonio's Eastside Promise Neighborhood project; and an adjunct professor at The University of Texas Austin College of Natural Science's Health Information and Health IT program. He also serves on the Texas Medical Association's Council on Science and Public Health.