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. 2022 Jul 8;3(7):e221874.
doi: 10.1001/jamahealthforum.2022.1874. eCollection 2022 Jul.

Association Between Self-reported Health-Related Social Needs and Acute Care Utilization Among Older Adults Enrolled in Medicare Advantage

Melanie Canterberry  1 , Jose F Figueroa  2   3 , Charron L Long  1 , Angela S Hagan  4 , Suhas Gondi  3 , Andy Bowe  1 , Stephanie M Franklin  4 , Andrew Renda  4 , William H Shrank  4 , Brian W Powers  4   5
Affiliations

Association Between Self-reported Health-Related Social Needs and Acute Care Utilization Among Older Adults Enrolled in Medicare Advantage

Melanie Canterberry et al. JAMA Health Forum. .

Abstract

Importance: There is increased focus on identifying and addressing health-related social needs (HRSNs). Understanding how different HRSNs relate to different health outcomes can inform targeted, evidence-based policies, investments, and innovations to address HRSNs.

Objective: To examine the association between self-reported HRSNs and acute care utilization among older adults enrolled in Medicare Advantage.

Design setting and participants: This cross-sectional study used data from a large, national survey of Medicare Advantage beneficiaries to identify the presence of HRSNs. Survey data were linked to medical claims, and regression models were used to estimate the association between HRSNs and rates of acute care utilization from January 1, 2019, through December 31, 2019.

Exposures: Self-reported HRSNs, including food insecurity, financial strain, loneliness, unreliable transportation, utility insecurity, housing insecurity, and poor housing quality.

Main outcomes and measures: All-cause hospital stays (inpatient admissions and observation stays), avoidable hospital stays, all-cause emergency department (ED) visits, avoidable ED visits, and 30-day readmissions.

Results: Among a final study population of 56 155 Medicare Advantage beneficiaries (mean [SD] age, 74.0 [5.8] years; 32 779 [58.4%] women; 44 278 [78.8%] White; and 7634 [13.6%] dual eligible for Medicaid), 27 676 (49.3%) reported 1 or more HRSNs. Health-related social needs were associated with statistically significantly higher rates of all utilization measures, with the largest association observed for avoidable hospital stays (incident rate ratio for any HRSN, 1.53; 95% CI, 1.35-1.74; P < .001). Compared with beneficiaries without HRSNs, beneficiaries with an HRSN had a 53.3% higher rate of avoidable hospitalization (incident rate ratio, 1.53; 95% CI, 1.35-1.74; P < .001). Financial strain and unreliable transportation were each independently associated with increased rates of hospital stays (marginal effects of 26.5 [95% CI, 14.2-38.9] and 51.2 [95% CI, 30.7-71.8] hospital stays per 1000 beneficiaries, respectively). All HRSNs, except for utility insecurity, were independently associated with increased rates of ED visits. Unreliable transportation had the largest association with increased hospital stays and ED visits, with marginal effects of 51.2 (95% CI, 30.7-71.8) and 95.5 (95% CI, 65.3-125.8) ED visits per 1000 beneficiaries, respectively. Only unreliable transportation and financial strain were associated with increased rates of 30-day readmissions, with marginal effects of 3.3% (95% CI, 2.0%-4.0%) and 0.4% (95% CI, 0.2%-0.6%), respectively.

Conclusions and relevance: In this cross-sectional study of older adults enrolled in Medicare Advantage, self-reported HRSNs were common and associated with statistically significantly increased rates of acute care utilization, with variation in which HRSNs were associated with different utilization measures. These findings provide evidence of the unique association between certain HRSNs and different types of acute care utilization, which could help refine the development and targeting of efforts to address HRSNs.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Figueroa reported personal fees from Humana during the conduct of the study, as well as grants from the Commonwealth Fund, the Robert Wood Johnson Foundation, the National Institute of Aging, and the Episcopal Health Foundation outside the submitted work. Dr Hagan, Ms Franklin, and Dr Renda reported equity holdings with Humana. Mr Gondi reported prior employment with Humana and the Commonwealth Care Alliance. Dr Shrank reported equity holdings with Humana and serving as a director at GetWellNetwork outside the submitted work. Dr Powers reported equity holdings with Humana and prior employment with Anthem and Fidelity Investments. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Unadjusted Rates of Acute Care Utilization by Presence of Health-Related Social Needs (HRSNs)
Hospital stays are an aggregate of inpatient admissions and observation stays. Avoidable hospital stays were defined using the Agency for Healthcare Research and Quality Prevention Quality Indicators definition. Avoidable emergency department (ED) visits were defined using the New York University ED visit algorithm and subsequent algorithm patch., All differences between beneficiaries with and without HRSNs across the 4 categories were statistically significant, with P values <.001.
Figure 2.
Figure 2.. Association Between Health-Related Social Need (HRSN) Burden and Rates of Hospital Stays or Emergency Department (ED) Visits
Incident rate ratios are calculated from negative binomial regression models estimating the association between HRSNs and utilization measures. Models adjust for age, sex, race and ethnicity, disability status, dual eligibility status, and Elixhauser Comorbidity Index score, with hospital referral region fixed effects. For all incident rate ratios, the reference population is beneficiaries with no HRSNs. Hospital stays were an aggregate of inpatient admissions and observation stays. Avoidable hospital stays were defined using the Agency for Healthcare Research and Quality Prevention Quality Indicators definition. Avoidable ED visits were defined using the New York University ED visit algorithm and subsequent algorithm patch.,
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