A driving force for health equity

Bridging the Gaps: Using Data to Understand the Social Determinants of Health

By: Erika Cottrell, PhD, MPP, OCHIN Investigator and Jean Baker, Patient Advisor for the Health Systems Demonstration III Project

Research suggests that the social determinants of health (SDH) – the conditions in which people are born, grow, live, work and age[i] – may contribute more to health outcomes than medical care. SDH include a wide range of social, economic and environmental factors such as availability of resources to meet daily needs (e.g., safe and affordable housing, healthy food), access to educational, economic, and job opportunities, social support, neighborhood and community safety, and clean air and water. Differences in these factors help to explain why some people experience better health than others, and why there continue to be such profound disparities in health outcomes in the United States.[ii] As part of its Healthy People 2020 initiative, the US Department of Health and Human Services highlighted the importance of creating “social and physical environments that promote good health for all” through action in five key SDH areas, as shown in Figure 1.[ii]

Figure 1:  Healthy People 2020 Approach to Social Determinants of Health

Figure 1: Healthy People 2020 Approach to Social Determinants of Health


Insurers are increasingly implementing policies that tie the amount of reimbursement that health care providers receive to measures of health care quality. These measures of health care quality are typically based on clinical outcomes of patients, such as the number of patients who have uncontrolled diabetes, or who goes to the emergency room. Reimbursement amounts do not take into account the SDH that impact health. Failure to incorporate SDH into health quality measures may explain why health care organizations that serve low-income patients often appear to perform poorly on quality measures relative to those serving patients with higher incomes.[III] There are concerns that ignoring patients’ SDH in quality measures may unfairly penalize providers that serve patients with complex needs and further compound the burden of health disparities on vulnerable populations. Therefore, fuller understanding of the impact of SDH on patient outcomes may have important implications for reducing disparities in health systems.

What are we doing?

Researchers from OCHIN and Kaiser Permanente Center for Health Research Northwest (CHR-NW) are using information on social needs from patients’ electronic health records (for example, a patient’s insurance status or household income) and data from the US Census and American Community Survey about the social conditions of the neighborhoods where patients live (for example, the percentage of individuals in the patient’s neighborhood who have an income below the federal poverty level) to understand how these factors impact specific outcomes like diabetes control and emergency department utilization. This study focuses on patients, communities, and providers in the states of Oregon and Washington.

In previous work on this topic, the study team found that SDH did indeed affect health outcomes in patients seen at community health centers from OCHIN and the OneFlorida health network. As expected, patients receiving care in these community health centers lived in more socially vulnerable communities than average US populations. We found that SDH and clinical factors explained more of the variation in clinic-level care quality – such as diabetes control or emergency department utilization – than accounting for clinical factors alone.

One limitation of previous work was that it focused only on clinics serving vulnerable populations and that the results may not apply in other patient populations. The study team at OCHIN and CHR-NW recently received additional funding from the Patient-Centered Outcomes Research Institute (PCORI) to expand this research beyond safety net clinics to a less vulnerable patient population (e.g., where a large percentage holds private health insurance). The collaboration between OCHIN and Kaiser Permanente CHR-NW enables us to look at patients from a broad mix of social circumstances and levels of social deprivation. Increasing the types of patients included in our study will give us a better understanding of the impact on health outcomes and health care utilization.

The study team wants to ensure that findings can help health care leaders improve delivery and policy. We are committed to engaging stakeholder advisors (patients, clinicians, communities, health systems leaders, policymakers/payers and other researchers) who understand those experiences best. These stakeholders provide regular and unique voices to help the study team evaluate the implications and utility of their findings, especially for clinical decision-making, system improvement and health care payment and policy. Stakeholder advisors will help the study team interpret the results of the study, provide context to vast amount of data, and communicate findings to the public, PCORI, and other research groups. The study team includes over 20 researchers and stakeholder advisors. The study is led by Erika Cottrell, PhD and Abby Sears, MBA, MHA, at OCHIN and Stephanie Fitzpatrick, PhD and Mary Ann McBurnie, PhD at the Kaiser Permanente CHR-NW.

This research is critical because it considers a larger context of factors that may affect a person’s or population’s health. What we learn from this study has the potential to impact how policymakers influence change within health systems and improve patient-centered health care.

If you have any questions, please contact Michelle Hendricks, PhD, OCHIN Project Director, at hendricksm@ochin.org.

OCHIN Grand Rounds

Dr. Erika Cottrell will be presenting outcomes from the Health Systems Demonstration Project at OCHIN’s Grand Rounds on April 12, 12:00 – 1:00 pm PT.  This Grand Rounds presentation will examine how OCHIN has collaborated with patient, provider, and health system stakeholders throughout all three phases of the Health Systems Demonstration project, and we will share the latest findings.

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[i] WHO, 2019, https://www.who.int/social_determinants/sdh_definition/en/

[ii] Healthy People 2020, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

[iii] Chien AT, Wroblewski K, Damberg C, et al. Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures? Journal of general internal medicine 2012;27(5):548-54. doi: 10.1007/s11606-011-1946-8 [published Online First: 2011/12/14]