Article In Brief
Even after adjusting for certain demographic factors, patients from neighborhoods with a low socioeconomic status had higher 30-day mortality rates for major neurologic disease categories compared with patients from neighborhoods with high socioeconomic status. Neurologists amd others who study social determinants of health discuss the ways individual neurologists and their institutions can mitigate these disparities in outcomes.
The socioeconomic status (SES) of the neighborhood or community where a person lives—not only their own socioeconomic position—plays an important role in how well they recover from hospitalization for a range of neurologic conditions, according to a new study from researchers at Duke University Health System published Feb. 15 in Neurology.
Neighborhood SES is strongly associated with 30-day mortality for many common neurologic conditions even after accounting for baseline comorbidity burden and individual socioeconomic status, the authors reported in a retrospective review of Medicare claims from 2017-2019. They included data for patients older than 65 hospitalized with multiple sclerosis and cerebellar ataxia, stroke, degenerative nervous system disorders, epilepsy, traumatic coma, and nontraumatic coma.
According to the paper, the authors measured “neighborhood socioeconomic status by the Area Deprivation Index, which uses socioeconomic indicators, such as educational attainment, unemployment, infrastructure access, income, etc. to estimate area-level socioeconomic deprivation at the level of census block groups.”
Even after adjusting for factors including age, sex, race/ethnicity, comorbidity burden, and individual SES, patients from low SES neighborhoods had higher 30-day mortality rates compared with patients from high SES neighborhoods for all disease categories except for multiple sclerosis. The magnitudes of the effect ranged from an adjusted odds ratio (aOR) of 2.46 for the non-traumatic coma group to 1.23 for the stroke group.
“The magnitude of the effect of neighborhood SES on outcomes for these conditions are substantial: after adjustment, 30-day mortality rates were 23 percent higher for stroke, 38 percent higher for degenerative nervous system disorders, 34 percent higher for epilepsy, 44 percent higher for traumatic coma, and 146 percent higher for non-traumatic coma in the low neighborhood SES group than the high neighborhood SES group,” the authors wrote.
“A much bigger takeaway is this: What can our hospitals and health systems be doing to invest in their neighborhoods and really uplift the communities that they are in?”—DR. ALTAF SAADI
“These effect sizes are especially shocking in the context of existing transformative interventions in neurology: for example, the use of mechanical thrombectomy combined with best medical therapy is associated with a 17 percent relative decrease in three-month mortality for patients with acute large vessel ischemic stroke. Notably, the increased rate of 30-day mortality in the stroke disease group is the smallest of the disease groups; by contrast, the 146 percent increased 30-day mortality for patients from low SES neighborhoods with non-traumatic coma is especially striking.”
Although the adjusted risk for hospital readmission was not significantly higher for patients from low SES neighborhoods overall, the authors also found that lower neighborhood SES is associated with substantially higher 30-day readmission rates specifically for patients with stroke and neurodegenerative diseases.
“These findings have broad implications for clinical practice, research, and future quality initiatives: researchers, policymakers, and practitioners should consider the effect of neighborhood socioeconomic deprivation when designing risk adjustment models, considering the effect of individual socioeconomic status, or performing place-based analyses of risk factors and outcomes,” the authors wrote.
“We were hoping to draw attention to the fact that individual clinicians need to have a better recognition that the SES of their patients and the characteristics of their neighborhoods are both important,” said the corresponding author, Brad Hammill, DrPH, associate professor in population health sciences and medicine at Duke University School of Medicine. “We tend to think about the risks to patients that are related to the care that they receive in the hospital, but so much of the risk patients incur happens outside the hospital, when they return to a neighborhood that maybe does not have the supports that they need.”
The study's results are consistent with neurovascular-focused literature that has found associations between neighborhood SES and health outcomes, said Hannah Gardener, ScD, an epidemiologist in the department of neurology at the University of Miami Miller School of Medicine who studies modifiable risk factors for clinical and subclinical vascular outcomes including stroke, myocardial infarction, carotid atherosclerosis, and cognitive decline.
“Other studies have also shown that not only does individual-level socioeconomic disadvantage increase the risk for poor health outcomes after hospitalization, but neighborhood-level socioeconomic factors also matter,” said Dr. Gardener, who was not involved with the study.
‘A Wakeup Call’
“This data should serve as a wakeup call,” said Leah Blank, MD, MPH, assistant professor of neurology at the Icahn School of Medicine at Mount Sinai in New York. “We have long known that socioeconomic disparities affect outcomes for people with all kinds of conditions, but we don't have as much data in neurology as we do in some other specialties, nor have we had data like this at the neighborhood level.”
“As an epilepsy specialist, seeing that an epilepsy patient from a lower SES neighborhood has a 30 percent increased risk of mortality after admission for seizure or epilepsy is very upsetting,” Dr. Blank added. “We know that many of these differences in adult neurologic outcomes start in childhood, based on education, nutrition, and exposure to air pollutants and lead in the water. All of these things are associated with where you live and your socioeconomic status can affect your health outcomes decades later.”
One study finding suggests that certain clinical and public health interventions may be working, said Magda Szaflarski, PhD, associate professor of sociology and a scientist in the Center for Clinical and Translational Science at the University of Alabama at Birmingham.
“The stroke group had the least disadvantage associated with SES, and I am familiar with multiple settings in which there is strong community outreach to address disparities in stroke care and outcomes,” she pointed out. “International stroke studies have really done a lot to inform community interventions, and that may be one of the reasons why we see a smaller difference in this group of patients than in others. Other neurologic conditions have not had as many broad, long-lasting public health initiatives built around them.”
“In stroke care, initiatives like the ‘Get with the Guidelines’ stroke program help different hospitals, regardless of the local context, to be able to follow best practices,” said Altaf Saadi, MD, MSc, assistant professor of neurology at Harvard Medical School and principal investigator in the Neurodisparities and Health Justice Lab at Massachusetts General Hospital.
“That's another tool that can help reduce some of the disparities we see,” she said. “With other conditions, there are fewer clinical practice guidelines and less dissemination of those best practices, and when you have that variability, it's easier for there to be disparate care.”
Identification of patients who are particularly vulnerable is key to better understanding the risks they face, Dr. Szaflarski pointed out.
“The researchers in this paper note that the electronic medical record [EMR] is a great source of data that could be informative about the vulnerabilities of some of these patients with neurologic conditions,” she said. “But EMRs do not reliably collect socioeconomic and neighborhood information, so ... we lack information that could help us better understand what we need to know about health outcomes as they relate to social conditions.”
While EMRs can link information about where patients live to US Census neighborhood-level SES data, Dr. Szaflarski noted, “information about their immediate social situation is typically not available.”
“In addition,” she said, “key data about the case, including clinical as well as any social and psychosocial assessments, are often contained in the notes section of the EMR rather than in structured fields, so special methods such as natural language processing are needed to extract that information.”
The study supports the need for systematic improvements to transitions of care, in which patients at risk of poor post-hospitalization outcomes because of both individual and neighborhood SES factors are flagged before discharge, Dr. Gardener said. “In order to design the most impactful interventions, we need to better understand which patients are at the highest risk for mortality and hospital readmission early post-discharge,” she said.
At the health system and policy level, Dr. Szaflarski said, the lack of a strong public health system is detrimental. “The US public system is not as advanced as in many other industrialized nations, and that is really hurting us,” she said. “Privatized health care in the United States has created conditions where many patients don't have regular access to care, and the quality of care is largely variable. Additionally, there is an acute shortage of neurology providers in all parts of the country except the Northeast.”
The current study found that the detrimental effects of neighborhood SES on neurologic outcomes persisted even after controlling for race, but the role of historic and contemporary structural racism in the evolution of depressed and disenfranchised neighborhoods is also undeniable, said Dr. Hammill.
“Within many metropolitan areas, neighborhoods subject to historical discrimination through mechanisms such as redlining will tend to have higher deprivation scores than other parts of those metropolitan areas.”
Redlining refers to local, state and federal housing policies that mandated segregation, such as the Federal Housing Administration's refusal to insure mortgages in and near African American neighborhoods.
The FHA's Underwriting Manual said that “incompatible racial groups should not be permitted to live in the same communities,” and recommended that highways be used to separate Black and white neighborhoods—one among a number of policies that led to the devastation of many thriving Black neighborhoods as interstate highways and other major roads cut through these communities, displacing residents and creating permanent barriers to economic opportunity.
A substantial body of evidence over the past three decades has captured the impact of racial residential segregation on health disparities. A seminal 2001 study in the journal Public Health Reports from authors at the University of Michigan and the University of Texas found that, by determining access to education and employment opportunities, segregation is a primary cause of racial differences in SES and remains a fundamental cause of racial differences in health.
“Segregation also creates conditions inimical to health in the social and physical environment,” the authors noted. They concluded that, “[E]ffective efforts to reduce racial disparities in health status should seriously grapple with reducing racial disparities in socioeconomic circumstances, and with targeting interventions not only at individuals but also at the geographic contexts in which they live.”
The authors concluded that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.
Living in poor, racially segregated neighborhoods is particularly predictive of significant health risks and a shorter lifespan for Black residents of those neighborhoods, according to “Health in the Segregated City,” a report from the NYU Furman Center.
“On average, disproportionally minority, and low income, neighborhoods provide lower quality educational and employment opportunities, expose residents to a disproportionate burden of unhealthy environmental risks, and discourage healthy behaviors by forcing residents to navigate degraded built environments and targeted advertising campaigns that encourage consumption of health damaging foods, alcohol, and other products,” the report noted.
“In combination with other risks, segregation contributes to striking health disparities over even extremely short distances. In Chicago, a few stops on the L can mean up to a sixteen-year gap in life expectancy, while just six subway stops separates neighborhoods with a 10-year difference in life expectancy in New York City.”
The health care system itself exacerbates the racial health disparities caused by residential segregation, the report found, noting that predominantly Black, racially isolated neighborhoods are more likely to offer fewer ambulatory facilities, more limited access to physicians, and a lower supply of surgeons.
A Bigger Role for Health Systems
But efforts by individual clinicians, departments, and hospitals to improve transitions of care and connection of higher-risk patients to needed services can only do so much, Dr. Saadi said. “A much bigger takeaway is this: What can our hospitals and health systems be doing to invest in their neighborhoods and uplift the communities that they are in?”
She cited examples of hospitals across the country investing in local affordable housing options and resources like supermarkets in “food deserts.”
“Here in Boston, Boston Medical Center along with Boston Children's Hospital and [Massachusetts General Hospital] recently put significant dollars behind affordable housing,” she said.
That doesn't mean that hospitals are becoming landlords. In 2017, Boston Medical Center announced that it would invest $6.5 million over five years to support a wide range of affordable housing initiatives, including a housing stabilization program for individuals with complex medical problems including substance use disorder and a stabilization fund providing grants to community-based organizations to help families avoid eviction. “BMC is making a long-term commitment to housing for health, and will reinvest loan repayments, equity fund returns, and tax credits from this initiative back into affordable housing,” said an institutional statement at the time.
In 2020, Massachusetts General Hospital invested $3.4 million to fund community-based initiatives aimed at tackling the health challenges of housing, increased access to behavioral health services through community health workers, and workforce development, including a $1.1 million investment to support affordable housing projects in Chelsea, Boston, Revere, and Winthrop.
Accelerating Investments for Healthy Communities—a program of the Center for Community Investment with support from the Robert Wood Johnson Foundation—is helping Boston Medical Center and five other hospitals and health systems (including Bon Secours Mercy in Maryland and Ohio Dignity Health in California, Maryland's Kaiser Permanente, Nationwide Children's in Ohio, and University of Pittsburgh Medical Center) deploy their assets to advance affordable housing as a way to create more equitable, sustainable, and healthy communities.
Hospitals and health systems also have a role in addressing food insecurity, another risk factor for poor health outcomes at both the individual and neighborhood SES levels.
Northwell Health's Food as Health Program—a partnership that includes Island Harvest, Long Island Cares Inc., the Harry Chapin Food Bank, God's Love We Deliver, US Foods, and Baldor—addresses factors contributing to food insecurity including affordability issues, a lack of nutritional awareness, transportation/mobility challenges, and difficulty in preparing meals.
At Northwell-affiliated LIJ Valley Stream hospital, 1 in 5 patients is food insecure. Patients with a diagnosis impacted by nutrition are screened, and those who identified as food insecure receive a nutrition consultation and navigation to community food resources. At discharge, they receive a two-day supply of fresh produce and non-perishable food and an “authorization” for two emergency food refills. If patients have transportation or mobility issues, emergency food supplies are delivered to their homes, and they're provided with navigation services to community food resources and entitlement programs.
In 2020, NYC Health + Hospitals, the largest public health care system in the nation, began a partnership with startup social-services prescriber NowPow to address housing and food insecurity among their patients. Housing and food navigators will be stationed in all 11 hospitals in New York City's public health system; they'll use NowPow to check patients' eligibility for services and match them with community resources, like Safe Haven beds, eviction prevention services, food pantries, and SNAP enrollment.
“We need to think of our health care institutions as more than just offering care to people who are sickbut [rather as] forces for change in our communities that can actively invest in our neighborhoods and address these social determinants of health,” Dr. Saadi said.
The study authors had no relevant disclosures.