Understanding the Value of Community Vital Signs in Primary Care
Condition: Colon Cancer; Breast Cancer; Cervical Cancer; Prostate Cancer; Cardiovascular Disease
MeSH terms: Cardiovascular Diseases
Study type: Observational

Summary: 
      Social determinants of health (e.g. the income, education, and environment of patients) may
      exert greater influence on health outcomes than traditional clinical factors (e.g. lab
      results, diagnoses, and family history). Calls for integrating primary care and public health
      are therefore increasing, but merging these domains of care is logistically difficult.
      Research is lacking on the incremental benefit of adding public health data at the practice
      level-- in improving either health outcomes or care delivery. This proof of concept pilot
      will merge data from electronic health records (EHRs) with community vital signs, a set of
      metrics that describes key community resources that affect health. The investigators will
      identify resource poor communities, or cold spots, based on four variables (education,
      poverty, life expectancy, and access to healthy foods) at the census tract level - referred
      to as a community vital sign. The hypothesis is that patients coming from cold spots are more
      likely to have worse health outcomes and that clinicians will deliver better care if they
      know a patient's community context and his/her specific social needs. This study will involve
      12 primary care practices in Northern Virginia that care for more than 170,000 patients.
      Patient addresses will be geocoded for each practice and determine which patients reside in
      cold spots for each community vital sign. The variation for each community vital sign for
      each practice's patients will be calculated and a bivariate and regression analyses will be
      used to determine whether coming from a cold spot is associated with worse clinical quality
      metrics. 15 clinicians will be alerted when they see a patient from a cold spot, patients
      will complete a social needs survey, and clinicians will prospectively document through
      surveys whether such knowledge affects interpersonal interactions (such as time spent with
      patients and the use of clearer language) or clinical management (such as referrals to care
      coordination or community resources). By pragmatically integrating community vital signs into
      care, this innovative proposal will seek to understand which community data clinicians value,
      how these data might influence care, and how best to incorporate these data into clinical and
      population care.
    

Detailed description: 
      The investigators will integrate community vital signs into clinical data, identify cold
      spots, and determine prospectively how clinicians use these community data at the point of
      care and for populations of patients. The investigators hypothesize that (1) the patients in
      a primary care practice live in a range of communities with different social determinants of
      health, including cold spots that lack health-promoting resources, (2) community vital signs
      are associated with patient health outcomes (e.g., being up-to-date with preventive care,
      control of chronic conditions, morbidity), and (3) knowing that a patient resides in a cold
      spot will help clinicians improve patient care.

      Aim 1a: Determine community vital sign cold spots in the catchment area of 12 primary care
      practices.

      Aim 1b: Determine whether patients residing in cold spots experience worse outcomes, such as
      receiving inadequate care, worse chronic disease control, or higher morbidity.

      Aim 2: Determine whether knowing a patient's community vital signs and social needs at the
      point of care will change clinical management; and explore how practices could use community
      vital signs for population care.

      Aim 3: Identify other community vital signs that practices would find useful for managing
      patients.
    

Intervention name(s): Community vital signs
Intervention type(s): Other
Intervention description(s): We will present clinicians with information about their patients' communities
Observational model: Ecologic or Community
Time perspective: Other
Sampling method: Non-Probability Sample
Study population: 
        Aims 1a and 1b: The participants include all unique patients seen at the 12 study practices
        (approximately 170,000 patients over the past two years). Aims 2 and 3: The clinicians in
        this analysis will include 15 participants recruited from the approximately 100 clinicians
        at the 12 practices - ideally 1-2 clinicians from each office. Because the study will
        characterize the upper bounds, or ideal outcomes, in the use of community vital signs,
        clinicians who are willing to participate and provide feedback will be selectively
        recruited.
      
Keywords: Primary health care; Public health; Medical Informatics; Social Determinants of Health