Social determinants of health are conditions in which people are born, grow, live, work and age and these forces and systems shape their daily lives and impact well-being and disease.1 The forces and systems that come into play in this arena are varied and diverse and include systems of health care delivery, economic policies, social norms and policies, health care developmental agendas, and political systems. These social determinants of health care are important in that they impact a wide variety of health, functioning, and quality of life outcomes. There is growing recognition that improving health care and achieving health equity, both in this country and throughout the world, will require more attention and broader approaches that address economic, environmental, and social factors that impact health.
Bennett et al outline six common domains of social determinants of health: 1) social stability, which includes issues related to employment, income, expenses, debt, medical bills and support; 2) neighborhood and physical environment, which includes issues of housing, transportation, safety, parks, playgrounds, and walkability; 3) education, which encompasses issues of literacy, language, early childhood education, vocational training, and higher education; 4) food, which covers issues related to hunger and access to healthy food options; 5) community and social context, which involves issues related to social integration, support systems, community engagement and discrimination; and 6) health care system-related parameters, which involves health coverage, provider availability, provider linguistic and cultural competency, and quality of care.2 These non-medical related factors, along with underlying genetics and health behaviors, are considered greater contributors to premature death than the quality of health care.3
At first glance, many of these social determinants of health do not appear to have much to do with pathology and laboratory medicine. However, there are a number of ways laboratories can provide support and assistance in tackling many of the problems that currently plague patients in these areas. Below are things to consider engaging your laboratory in to help address social determinants of health.
1) Learn and understand what the issues are and engage your community and leadership in discussion. The first step in trying to address an issue is to understand it. Take the opportunity to see what people are saying in the literature about it. Try to find opportunities to engage the local community and leadership regarding issues that are particularly relevant in the communities served by your laboratory and programs that are currently in place in your area. There may be opportunities to facilitate laboratory testing and help with issues of cost of testing. The local Community Health Needs Assessment (CHNA), which federally tax-exempt hospitals are asked to conduct on a regular basis in conjunction with local and public health departments and community input, can provide information regarding disparities and health issue concerns for the local community. Leadership can help with addressing issues related to financial and staffing resources, administrative issues, and logistical barriers that might stand in the way of addressing patients’ needs.
2) Assess your own laboratory’s readiness to implement plans of action. Despite best intentions, most health care delivery teams have internal biases and issues which may impede the development and execution of plans. For example, if someone in a key leadership position has an issue with opioid addiction, they subconsciously may be less engaged and empathetic in trying to come up with plans and executing them in an attempt to interact and help that segment of the population. Issues that need to be considered in recruiting the necessary resources to implement a plan of action include financial needs, staffing needs, existing supportive resources, clarity on the focus of a program, and a method to assess one’s capability to implement a program of action. In defining a plan of action, one needs to select which social determinant(s) one wishes to specifically target, select a health outcome to track, define the target patient population, and consider the logistical issues one needs to address. In many instances, the primary drivers of such plans are our clinical colleagues from other specialties. That being said, having a seat at the proverbial table when planning is being done is important. Pathologists and laboratory professionals have an expertise to bring to that table that might prove useful, ranging from issues related to logistics of testing to which tests can be best used to help monitor program implementation progress and assess the impacts of interventions for patients.
3) Evaluate and refine plans and workflows. As a particular program is implemented, continued assessment and monitoring of the implementation is important. Constant monitoring and assessment of laboratory testing being employed and what impact the testing is having and which logistical issues are associated with order and performing and reporting test results is important. Data collected from such testing may be useful in uncovering other needs and gauging the success or failure of a program. Often, laboratory data may be part of results published in the literature about a program.
4) Data collection and analysis. Pathology input regarding management and communication of laboratory data collected before and during implementation of a program, informatics, and the economic issues related to laboratory testing and costs is critical. The collection and analysis of such information can potentially pave the way toward examining ways to reduce reimbursement for traditional pathologist activities, create new opportunities for value creation and foster creatively thinking about new compensation models.4 Crawford and colleagues have outlined multiple potential opportunities that diagnostic management teams can provide from a laboratory perspective according to “Clinical Lab 2.0”; these may include such things as reducing time to diagnosis and time to intervention, closing gaps in care via alerts or notifications and tracking of clinical outcomes, powering wellness care screening by including triggering early intervention, triggering real-time risk escalation and intervention, coordination of laboratory and pharmacy efforts for acute conditions (such as antibiotic use) as well as chronic disease management, and building the evidence base for the efficacy and utility of precision medicine, pharmacogenomics and population level interventions.5
The recent COVID-19 pandemic highlighted the critical role the laboratory played as part of healthcare delivery worldwide. The lab was at the center of health care delivery and provided a means by which care was triaged, as opposed to being a secondary player and ancillary cost center. Testing and data collected from testing helped managed the epidemic. Although this played out on the grand world stage, similar impacts can be had in the smaller arenas focused on social determinants of health. To quote James Crawford, Chair of the Board of Project Santa Fe Foundation, “There has never been a better time to demonstrate the value of laboratory medicine and pathology in the delivery of healthcare—but it must be quantitatively proven and attributable to the lab’s contribution.”6
References
1. About Social Determinants of Health. World Health Organization. Accessed May 17, 2021. shd definition.
2. Bennett NM, Brown MT, Green T, Hall LL, Winkler AM. Addressing social determinants of health (SDOH): beyond the clinic walls. Accessed May 17, 2021. htps://edhub.ama-assn.org/step-forward/module/2702762.
3. Schroeder SA. Sattuck Lecture. We can do better- improving the health of the American people. New Engl J Med 2007; 357(12): 1221-1228.
4. Ducatman BS, Ducatman AM, Crawford JM, Laposata M, Sanfilippo F. The value proposition for pathologists: A population health approach. Acad Pathol 2020. DOI: 10.1177/2374289519898857.
5. Crawford JM, Shotorbani K, Sharma G, Crossey M, Kothari T, Lorey TS, Prichard JW, Wilkerson M Fisher N. Improving American healthcare through “Clinical Lab 2.0”: A Project Sante Fe report. Acad Pathol 2017; 4 doi:10.1177/23742895177011067.
6. Shotorbani K, Orr J, Landsman K. Priming the clinical laboratory for population health. 2020. Priming the clinical laboratory for population health.