How doctors can address health inequity through SDOH

In 2020, two forces converged to shine a spotlight on the dramatic healthcare inequities in the United States: The emergence of COVID 19, and the Black Lives Matter movement, reinvigorated by the killing of George Floyd.  

As a result, healthcare providers are taking steps to address the social determinants of health (SDOH)—the expansive network of social, environmental, economic, and interpersonal factors and conditions that play a significant role in the health and well-being of patients.

Root causes of health inequities

Patients who experience the downstream adverse effects of SDOH are at an increased risk of poor health outcomes, particularly those with heart failure. Physicians can mitigate harm caused to patients experiencing downstream SDOH and heart failure by first addressing the link between the two.

According to a 2020 statement by the American Heart Association, treatment for heart failure routinely consists of guideline-directed medical therapy. Efforts are aimed at improving symptoms and quality of life while optimizing care to minimize the length and frequency of hospital visits.

While sticking to the treatment plan may work for some, managing heart failure is complicated for patients who are experiencing harmful effects of SDOH, largely due to limited access to medical care.

Patients who lack the financial means to afford proper care are often forced to choose between stable housing, food for their families, and treatment for their health challenges. For many, the choice is clear: Meet basic needs now and address chronic health issues later.

Because some patients with heart failure and SDOH have limited funds reserved for treatment, they may experience exacerbated symptoms and repeated hospitalizations.

One 2020 study published in the Journal of the American Heart Association found that 90-day mortality post-hospitalization was almost three times as likely in patients with heart failure who experienced downstream SDOH when compared with patients who had heart failure alone.

The study looked at patients with heart failure who were at least 65 years old and who had survived an adjudicated hospitalization due to their condition. The patients were also Medicare beneficiaries.

Over 10 years, 79 of the 690 total participants died within 90 days of their hospitalization. Of those deaths, 39% of patients had one or more SDOH, 32% had two or more SDOH, and 28% had no SDOH.

Poor health outcomes are therefore a direct result of the negative effects of SDOH in patients with heart failure, driving the long-term goal of health equity further away.

Optimize your practice

The good news is, physicians can take actionable steps to address health inequities.

The American Heart Association encourages physicians to implement SDOH assessment tools and corresponding data collection systems for individual and community care planning and record-keeping.

The group also urges doctors to collaborate with community partners to curate programs that identify patients who struggle with heart failure, as well as any SDOH-related needs they may have.

Creating clearly defined roles for staff members to navigate SDOH-related concerns with the skillful support of nurses, physicians, social workers, dieticians, and therapists will garner even more support for patients with heart failure who may not have access to the care they require.

A new vocabulary

Another tool physicians can use to address SDOH in patients is a set of standardized terms designed to aid in conversations about SDOH. Better health outcomes, lowered costs, and increased health equity are goals that require physicians and other healthcare professionals to get on board with this new vocabulary.

In addition to SDOH, the authors of an article published by the American Medical Association, state that it’s crucial for doctors to familiarize themselves with additional terms or concepts to effectively communicate with the matters at hand:

• Structural determinants: These encompass the socioeconomic, political, and macroeconomic climates as they are shaped by hierarchical intersections of identity and status such as race, sex, class, and power. 

• • Structural determinants are usually defined by boundaries relating to politics and culture, as well as economic relationships in cities, states, and the world at large.

• Social needs: These are basic material resources and psychosocial circumstances required by patients to maintain long-term positive health outcomes.

• Levels of change: This describes changes on the micro, meso, and macro levels. 

• • The micro level includes direct actions for the well-being of individuals, while the meso level involves working with groups to enact cultural and social changes. 

  • The macro level typically calls on legislative officials and policy makers to act on a large scale across entire communities, states, and countries, and shift widespread cultural narratives.

• Community health: This describes using public health science and evidence-based strategies to work with communities to optimize health and quality of life in a culturally appropriate manner.

• Population health: This refers to the health outcomes in a particular group, which also takes into account the distribution of those outcomes within the group.

• Public health 3.0: This model places emphasis on collaborative engagement and actions that affect SDOH to more effectively confront inequitable conditions.

The power of your practice

In the meantime, healthcare providers can take their cue from the American Heart Association by supporting social justice advocates and policy makers who are fighting for legislative change to help patients struggling because of SDOH and heart failure.

While no single doctor can dismantle the systemic challenges that cause SDOH risk, physicians can learn how to talk about these issues. In doing so, doctors might just position themselves to address SDOH and begin to mitigate health inequities.

Sources

1. Gara C. Black Lives Matter in Medicine: What Must Change? Hopkinsmedicine.org. 2020.

2. Henry, T. 7 terms doctors should know about social determinants of health. American Medical Association. 2021.

3. Sterling MR, Ringel JB, Pinheiro LC, et al. Social determinants of health and 90‐day mortality after hospitalization for heart failure in the regards study. Journal of the American Heart Association. 2020;9(9):e014836.

4. White-Williams C, Rossi LP, Bittner VA, et al. Addressing social determinants of health in the care of patients with heart failure: a scientific statement from the american heart association. Circulation. 2020;141(22):e841-e863.