Patients who were screened at health clinics and then helped getting food, medication and other necessities saw subsequent improvements in blood pressure and cholesterol levels, a new study shows. These findings provide some of the first hard data linking intervention and outcome, although they do not prove that addressing social needs improves clinical indicators.
The study was published Monday in JAMA Internal Medicine by Massachusetts General Hospital and Health Leads, a not-for-profit that screens patients for unmet social needs and helps connect them with relevant resources in their communities.
“What we really learned here is that there's at least some suggestion that there can be a clinical benefit to this type of approach,” said Dr. Seth Berkowitz, the study's corresponding author and an internist at Massachusetts General. “We'll certainly need to have some more studies, but I think overall it suggests that this may be something we can do to help folks who are struggling.”
Addressing social needs has traditionally been considered outside the purview of medical care, and before health systems begin to broadly adopt programs such as Health Leads, they'll need to know whether the costs and effort are worthwhile, even as the clinical benefits appear intuitive.
“Something like return on investment, what do you get out of what you put in for this, is certainly a very important topic for these kinds of interventions,” Berkowitz said.
So far, precise numbers remain unclear, but Berkowitz pointed to two areas in particular where interventions could lower costs: quality and pay-for-performance contracts, and healthcare utilization. For providers with pay-for-performance agreements under which their patients must reach certain outcomes, addressing social needs could be one tool to help patients get there. And if these interventions can actually help prevent expensive medical events such as heart attacks that send patients to the emergency room, they can reduce costs as well.
In the study, researchers looked at blood pressure, cholesterol and blood sugar in 5,125 people who visited three of Massachusetts General's primary-care clinics from October 2013 through April 2015. Of these, 1,774 screened positive for unmet resources and 1,021 enrolled in a Health Leads program. Those who joined the Health Leads program saw improvements in their blood pressure and cholesterol, although not in their blood glucose levels.
The researchers compared cohorts of patients in several ways to discern those improvements. They used data from electronic health records to track blood pressure, cholesterol and blood glucose levels from October 2012 through September 2015, a period that began at least a year before and ended at least five months after the Health Leads intervention.
Then, the researchers compared the level of improvement among patients who screened negative for unmet social needs and those who screened positive. Among those that screened positive, they also examined the outcomes of patients who enrolled in Health Leads against those who did not.
This difference-in-differences approach was designed to subtract factors or programs besides Health Leads that would influence patient outcomes, thereby isolating the impact of the Health Leads' intervention. It was not a randomized controlled trial, which could give researchers the ability to infer that Health Leads had actually caused the improvements in health.
“We weren't able to do a straightforward randomized controlled trial in this case, so we had to make use of other epidemiological tools to study what was going on,” Berkowitz said. “We felt it would be unethical to identify people with unmet needs and then not address them when we had the ability to.”
Future studies might also look at the broader or longer-term effects of such social-needs interventions, Berkowitz suggested, such as whether they actually reduce the incidence of heart attacks or lower healthcare utilization.
As for why cholesterol and blood pressure levels improved but blood sugar did not, Berkowitz said he did not know. However, he theorized that medication on its own has a bigger impact on cholesterol and blood pressure, whereas blood sugar also depends heavily on one's diet. For Health Leads advocates to help patients access or pay for medications is fairly straightforward; for them to change a person's diet is more complicated.
Recognition is growing among clinicians, researchers, payers and policymakers that a broad array of social determinants—economic stability, environment, education, community and access to food—can sway mortality, morbidity, life expectancy, healthcare costs and other health-related outcomes.
In January, the CMS announced it was putting $157 million into a pilot project to test whether screening patients and helping them with social needs outside of healthcare settings can improve their health.
The precise extent to which social factors affect health is challenging to gauge, but the consensus is that where and how people live, play and work has a significant impact on their health.
One estimate, published in the New England Journal of Medicine in 2007, suggested that premature death was determined 40% by behavioral patterns, 30% by genetic predisposition, 15% by social circumstances and 5% by environmental exposure. Healthcare, meanwhile, contributed just 10%.
