Disclosures: Davidson and Khan report no relevant financial disclosures. Please see the paper for all other authors’ relevant financial disclosures.
July 14, 2020
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USPSTF develops plan to address social determinants of health in primary care

Disclosures: Davidson and Khan report no relevant financial disclosures. Please see the paper for all other authors’ relevant financial disclosures.
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The United States Preventive Services Task Force has developed a plan for creating primary care-based recommendations regarding social determinants of health, according to a position paper published in the Annals of Internal Medicine.

The Task Force is working to develop these recommendations in recognition of the impact that social determinants of health (SDoH) have on a person’s well-being.

Quote from Davidson on USPSTF framework for social determinants of health

SDoH include resources such as access to food, housing, economic and social relations, education, health care and transportation, and the conditions and structural determinants in which people are born, work, and live, as well as their age.

“The good news is that the Task Force has always considered SDoH and social risks when making its recommendations,” Karina W. Davidson, PhD, MASc, Task Force vice-chair and senior vice president of research and dean of academic affairs at Northwell Health, told Healio Primary Care. “We have a long-standing commitment to promoting the health equity and well-being of Americans — including disadvantaged populations and those with varying social needs through our evidence-based recommendations.”

Davidson, who is also director of the Center for Personalized Health at Feinstein Institutes for Medical Research, noted that the Task Force has previously established SDoH-related recommendations for intimate partner/domestic violence, alcohol and tobacco use, obesity, healthy lifestyle and depression.

“By proactively searching for data on diverse populations, calling for new research to fill in existing gaps, and communicating as clearly as possible about how to support people’s varying health needs, we are hopeful that our approach will help improve equity in preventive care,” she said.

Developing framework to address SDoH

According to Davidson and colleagues, a number of considerations need to be made when making recommendations on clinical preventive services in primary care settings.

One such consideration, they said, is that modifiable factors — such as food insecurity and transportation — should be the target of intervention recommendations on social determinants and risks. Although nonmodifiable factors — including birthplace, age, race and ethnicity — may be key in determining screening needs, they are not appropriate intervention targets, Davidson and colleagues wrote.

They stressed that screening and SDoH interventions should take place in a primary care setting or be referred by a primary care physician.

When considering implementing SDoH into recommendations, the USPSTF creates a portfolio of evidence through key search questions. These general questions include examining whether there are valid and reliable screening tools available for primary care-related SDoHs and whether screening for the SDoH leads to decreased morbidity or mortality caused by relevant health conditions.

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The Task Force also considers whether there are feasible methods to deliver or refer interventions to address SDoH outcomes in primary care and how robust the associations are between intermediate health outcomes and health conditions.

Incorporating SDoH into recommendations

Based on their framework for developing primary care-based recommendations for SDoH, USPSTF suggested three approaches to address them in their future recommendations.

The first approach involves setting SDoHs as a new topic for evidence review and recommendation. For this to occur, SDoHs would need to be nominated as a potential screening or preventive intervention recommendation, and then follow the standard recommendation development process.

Another approach would be to use SDoHs to assess risks, burden of disease and the amount of net benefits derived from a USPSTF recommendation. According to researchers, the USPSTF consistently notes that SDoHs such as age, gender and race/ethnicity can increase the burden of disease, including in their recommendations regarding lung cancer and type 2 diabetes. SDoHs have also been used routinely in USPSTF recommendations based on risks associated with certain social determinants, such as in the recommendation for syphilis screening among people who have been incarcerated.

According to Davidson and colleagues, SDoHs may also affect the net benefit of a recommendation. For instance, patients with limited computer access may not experience the full benefits of an intervention that requires printed educational material or the use of a website.

The final approach proposed by Davidson and colleagues is for USPSTF to consider SDoHs in implementing recommendations. They noted that their recommendations for colorectal cancer screening emphasized evidence regarding the disparities observed among Black adults in screening, follow-up and treatment that may have led to increased cancer mortality.

“The Task Force has outlined a framework for the types of research that will help further our focus in this area, and we are looking forward to being able to review and consider new research in this critical area to improve care for all Americans,” Davidson said.

Addressing SDoHs in primary care

Photo of Ali Khan
Ali Khan

“The move by the USPSTF to invest in a rigorous, evidence-driven and nuanced approach to social risk in health is nothing short of a validation — a validation of the work that so many of us do, day after day, to investigate and alleviate that risk,” Ali Khan, MD, MPP, FACP, executive medical director at Oak Street Health and faculty member in the department of medicine at the University of Chicago’s Pritzker School of Medicine, told Healio Primary Care. “The structure for future investigation laid out by the USPSTF will only bolster that work, and further legitimize efforts to prevent the negative impacts of social determinants on health, in the eyes of the countless stakeholders crucial to make that real.”

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Khan noted that at his practice, which focuses on the needs of vulnerable older adults and Medicare enrollees, many patients face challenges in accessing secure housing, healthy food, transportation, internet and income, among other social risks.

“These are all barriers to accessing health care, and they are often quite difficult to overcome,” he said. “We work to address these head on, in an integrated, multimodal fashion, to minimize those barriers as best we can.”

Khan said, for example, that his practice offers patients door-to-door transportation for visits.

In addition, he noted that the practice engages social workers, community health workers and clinicians work to help patients find safe, secure housing and sources of income. They also use community centers to provide patients with internet access and social programs for exercise, wellness, nutrition and civic engagement.

“It’s in our interest to lean in as far as possible to address health in all aspects, and that’s what we continue to do, every day,” Khan said.