Capsule Commentary on Schickedanz et al., Impact of Social Needs Navigation on Utilization Among High-Utilizers in a Large Integrated Health System: a Quasi-Experimental Study

In this prospective evaluation of a large health-related social needs screening and navigation program for predicted high utilizers of healthcare services, Schickedanz et al. estimate a small decrease in healthcare utilization that is not statistically significant, when comparing those screened to all other predicted high utilizers. However, when restricting their analyses to subgroups with census tract indicators of lower socioeconomic status or with Medicaid insurance, they estimate both clinically meaningful and statistically significant reductions in healthcare utilization. The reasons for high utilization are quite heterogeneous, so examining subgroups more likely to have the health-related social needs that the intervention is meant to address makes sense. The results of this high-quality evaluation have important implications for both research and clinical operations within healthcare systems

Capsule Commentary on Landon et al., “Trends in Diabetes Treatment and Monitoring Among Medicare Beneficiaries”

In this study of Medicare claims (2007–2014) from older individuals with type 2 diabetes, Landon et al. highlight a mix of encouraging and discouraging findings. One caveat in interpreting their findings is that diabetes treatment guidelines are consensus-based, and we often do not know what proportion of patients the guidelines apply to, or what proportion of patients receiving particular treatments is appropriate

Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States

Food insecurity affects 1 in 8 US households and has clear implications for population health disparities. We present a person-centered, multilevel framework for understanding how individuals living in food-insecure households cope with inadequate access to food themselves and within their households, communities, and broader food system. Many of these coping strategies can have an adverse impact on health, particularly when the coping strategies are sustained over time; others may be salutary for health. There exist multiple opportunities for aligning programs and policies so that they simultaneously support food security and improved diet quality in the interest of supporting improved health outcomes. Improved access to these programs and policies may reduce the need to rely on individual- and household-level strategies that may have negative implications for health across the life cours

Gaps in the welfare state: A role-based model of poverty risk in the U.S.

Background Research clearly demonstrates that income matters greatly to health. However, income distribution and its relationship to poverty risk is often misunderstood. Methods We provide a structural account of income distribution and poverty risk in the U.S., rooted in the 'roles' that individuals inhabit with relation to the 'factor payment system' (market distribution of income to individuals through wages and asset ownership). Principal roles are child, older adult, and, among working-age adults, disabled individual, student, unemployed individual, caregiver, or paid laborer. Moreover, the roles of other members of an individual's household also influence an individual's income level. This account implies that 1) roles other than paid laborer will be associated with greater poverty risk, 2) household composition will be associated with poverty risk, and 3) income support policies for those not able to engage in paid labor are critical for avoiding poverty. We test hypotheses implied by this account using 2019 and 2022 U.S. Census Current Population Survey data. The exposure variables in our analyses relate to roles and household composition. The outcomes relate to income and poverty risk. Results In 2019, 40.1 million individuals (12.7% of the population) experienced poverty under the U. S. Census' Supplemental Poverty Measure. All roles other than paid laborer were associated with greater poverty risk (p < .001 for all comparisons). Household composition, particularly more children and disabled working-age adults, and fewer paid laborers, was also associated with greater poverty risk (p < .001 for all comparisons). Five key policy areas- child benefits, older-age pensions, disability and sickness insurance, unemployment insurance, and out-of-pocket healthcare spending-represented gaps in the welfare state strongly associated with poverty risk. Conclusions The role one inhabits and household composition are associated with poverty risk. This understanding of income distribution and poverty risk may be useful for social policy

Diabetes and the Built Environment: Evidence and Policies

Purpose of Review: To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure. Recent Findings: A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways—physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Summary: Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment

Detecting Anomalies among Practice Sites Within Multicenter Trials: An Application of Transportability Methods to the TOPCAT and ACCORD BP Trials

Background: Recent multisite trials reveal striking heterogeneities in results between trial sites. These may be because of population differences indicating different treatment benefits among different types of participants or site anomalies, such as failures to adhere to study protocols that could negatively affect study validity. We sought to determine whether a new data analysis strategy - transportability methods - could suggest site anomalies not readily identified through standard methods. Methods and Results: We applied transportability methods to 2 large, multicenter cardiovascular disease treatment trials: the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist; n=3445) comparing spironolactone to placebo for heart failure (for which site anomalies were suspected) and the ACCORD BP trial (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure; n=4733) comparing intensive-to-standard blood pressure treatment (for which site anomalies were not suspected). The transportability methods give expected results by standardizing from one site to another using data on participant covariates. The difference between the expected and observed results was assessed using calibration tests to identify whether treatment-effect differences between sites could be explained by participant population characteristics. Standard regression methods did not detect heterogeneities in TOPCAT between Russia/Georgia study sites suspected of study protocol violations and sites in the Americas (P=0.12 for difference in primary cardiovascular outcome; P=0.20 for difference in total mortality). The transportability methods, however, detected the difference between Russia/Georgia sites and sites in the Americas (P<0.001) and found that measured participant characteristics did not explain the between-site discrepancies. The transport methods found no such discrepancies between sites in ACCORD BP, suggesting participant characteristics explained between-site differences. Conclusions: Transportability methods may be superior to standard approaches for detecting anomalies within multicenter randomized trials and assist data monitoring boards to determine whether important treatment-effect heterogeneities can be attributed to participant differences or potentially to site performance differences requiring further investigation

Focusing on population health at scale — Joining policy and technology to improve health

Progress in biomedical innovation and technology has resulted in unprecedented improvements in human health. But population health is influenced by more than medical technology or health care services. Socioeconomic, psychosocial, and behavioral factors — including access to basic needs such as food, housing, and transportation — are major contributors to health and cost outcomes

Cash Benchmarking For Integrated Health Care And Human Services Interventions: Finding The Value Added

Health-related social needs, which include food insecurity, housing instability, and lack of transportation, are strongly associated with poor health outcomes, more health care use, and higher health care spending. Integrating human services that address health-related social needs into health care may address these issues. In this article we propose an innovative methodological approach (borrowed from developmental economics) called cash benchmarking, which can help determine when health care and human services integration is most useful. This is important because while integrating human services into health care offers potential benefits, it also comes with potential downsides-including the medicalization of social needs; deemphasis of upstream societal causes of health-related social needs, such as tax policy and labor conditions; and opportunity costs within the health care system, as resources are shifted to delivering social care. Ultimately, cash benchmarking can help stakeholders navigate closer to the promise, and away from the pitfalls, of health care and human services integration

Addressing Health-Related Social Needs: Value-Based Care or Values-Based Care?

Health-related social needs, such as food insecurity, housing instability, and lack of transportation, are associated with worse health outcomes, and are increasingly the focus of health-related social needs interventions within healthcare. Adoption of health-related social needs interventions is often justified by the potential to reduce healthcare costs. However, this can present a conundrum to clinicians. Physicians are often more accustomed to justifying clinical innovation based on improvements in health, in accord with the fundamental values of the medical profession, which include using our knowledge, skills, and the resources at our disposal to improve both individual and public health. In cases where health-related social needs interventions improve health but are not cost-saving, these two types of justifications can conflict. We provide a framework for considering these issues, and an agenda for scholarly work on this topic. Ultimately, if promoting patient and public health are key values for our profession, then understanding when to emphasize values-based care, rather than simply value-based care, is crucial to fulfilling our professional duty

Unified Approach Needed to Implement Nutrition Support Services - Reply

In Reply We appreciate the thoughtful letter from Rediger and Miles regarding our study and offer a few additional points. Given the importance of nutrition for health, we share the view that a broad range of nutrition options should be available to patients. In our view, medically tailored meal programs are one important tool that we hope becomes more widely available