The Association Between Neighborhood Socioeconomic and Housing Characteristics with Hospitalization: Results of a National Study of Veterans

Abstract

Background: Social determinants of health (SDOH) have an inextricable impact on health. If remained unaddressed, poor SDOH can contribute to increased health care utilization and costs. We aimed to determine if geographically derived neighborhood level SDOH had an impact on hospitalization rates of patients receiving care at the Veterans Health Administration's (VHA) primary care clinics.

Methods: In a 1-year observational cohort of veterans enrolled in VHA's primary care medical home program during 2015, we abstracted data on individual veterans (age, sex, race, Gagne comorbidity score) from the VHA Corporate Data Warehouse and linked those data to data on neighborhood socioeconomic status (NSES) and housing characteristics from the US Census Bureau on census tract level. We used generalized estimating equation modeling and spatial-based analysis to assess the potential impact of patient-level demographic and clinical factors, NSES, and local housing stock (ie, housing instability, home vacancy rate, percentage of houses with no plumbing, and percentage of houses with no heating) on hospitalization. We defined hospitalization as an overnight stay in a VHA hospital only and reported the risk of hospitalization for veterans enrolled in the VHA's primary care medical home clinics, both across the nation and within 1 specific case study region of the country: King County, WA.

Results: Nationally, 6.63% of our veteran population was hospitalized within the VHA system. After accounting for patient-level characteristics, veterans residing in census tracts with a higher NSES index had decreased odds of hospitalization. After controlling all other factors, veterans residing in census tracts with higher percentage of houses without heating had 9% (Odds Ratio, 1.09%; 95% CI, 1.04 to 1.14) increase in the likelihood of hospitalization in our regional Washington State analysis, though not our national level analyses.

Conclusions: Our results present the impact of neighborhood characteristics such as NSES and lack of proper heating system on the likelihood of hospitalization. The application of placed-based data at the geographic level is a powerful tool for identification of patients at high risk of health care utilization.

Keywords: Cohort Studies; Comorbidity; Hospitalization; Housing Issues; Patient-Centered Care; Population Health; Primary Health Care; Social Determinants of Health; Socioeconomic Status; United States Department of Veterans Affairs; Veterans Health; Washington.