From the Editors’ Desk: It’s the Social Determinants, Stupid

One of the frustrations of medical practice is the struggle to help patients trapped by circumstances of homelessness, poverty, illiteracy, addiction, and mental illness. Almost all internists, whether hospital- or office-based, are familiar with these scenarios: A 54-year-old homeless man is admitted and treated for cellulitis, only to be discharged to his riverbank encampment, where he promptly develops another infection. An 83-year-old female nursing home resident is admitted six times in as many months for urinary tract infections, bedsores, and delirium. A 37-year-old woman with multiple sclerosis and diabetes breaks her motorized wheelchair, and for lack of a replacement part, cannot pick up her medications at the local pharmacy or make it in for scheduled clinic visits. Feeling ill, with a fingerstick glucose of 508, she has the paramedics bring her to the ED. Let’s re-run these scenarios under a different lens. What if the homeless man could be discharged to transitional housing, where a team of social workers, addiction specialists, and health aides could attend to his physical, mental, and social needs? What if the woman with dementia resided in a Green House (thegreenhouseproject.org)—small, home-like residences where nurses and other staff are committed to knowing and caring for residents as individuals? What if the wheelchair-using patient didn’t have to call 911 for equipment failures but could easily access intensive case management services like those available through the Camden Coalition (New YorkerMagazine, January 24, 2011). Impossibly expensive? One would think so, particularly in the current economic doldrums. However, as Elizabeth Bradley and Lauren Taylor describe in the New YorkTimes (December 8, 2011), if you count combined expenditures on health and social services, the United States (29% of GDP) lags far behind other countries including Sweden, France, the Netherlands, Belgium, and Denmark (33% to 38% of GDP). These countries happen to have much better health statistics (life expectancy, infant mortality, potential life years lost). Shifting resources from health care to social services might just improve health at less cost. In this issue of JGIM, social determinants of health feature prominently. Billimek and Sorkin analyzed data from patients with type 2 diabetes participating in the California Health Interview Survey. After adjusting for individual health and sociodemographic characteristics, they found that self-reported poor neighborhood safety was associated with delays in filling prescriptions. Interestingly, neighborhood safety was not correlated with performance of technical quality indicators (e.g. annual A1c measurement). Although these findings require confirmation, they suggest that neighborhood characteristics could contribute to poor outcomes even when technical process quality is preserved. In a different vein, Jha and Epstein surveyed board chairpersons of 722 not-for-profit hospitals. They found that boards predominantly serving African-Americans placed lower priority on quality measurement and management than those serving non-African Americans. Although the absolute differences between these hospitals were modest, the findings raise concerns that minority-serving hospitals may not focus on quality improvement to the same degree as others. Of course, they may have good reason: many hospitals in African-American neighborhoods face intense financial pressures and crushing social problems. Like primary care doctors facing multiple competing demands, these hospitals are unlikely to change the way they do business without incentives and support. An increased focus on the social determinants of health is an essential element of any strategy to achieve the triple aim of better care, better health, and reduced costs. However, it is hard to be optimistic about the political prospects for new government programs addressing poverty. Perhaps the way in is through the back door. Rising health care costs threaten our national solvency. If increased spending on targeted social programs can be shown to reduce medical expenditures, well, that’s an outcome both Democrats and Republicans could love.