1. Write a brief paragraph discussing what social determinants are most relevant to your area of research and why. Consider both structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances, as described in the WHO reading. Explain why you chose the factors (might use Braveman article from last week to provide justification. The association could be reported in published research or it could be your hypothesized relationship. Consider whether how these factors might function over the lifecourse and/or intergenerationally.
My research centers around policy evaluation in kidney disease, and I am proposing to evaluate the effect of social risk factor adjustment in alternative payment models in kidney care. New payment models incentivize dialysis units and physicians based on their rate of home dialysis uptake (both peritoneal and home hemodialysis). This may penalize dialysis units and physicians that serve patients with more social risk factors, such as homelessness or housing insecurity, lack of social support, low socioeconomic status, or other factors. Not accounting for these social risk factors in risk adjustment may disproportionately penalize these units and physicians. I propose to use the Accountable Health Communities Screening Tool to assess social needs amongst the chronic kidney disease and end-stage kidney disease population, and the association of these social needs with home dialysis uptake and other outcomes. The most relevant social determinants assessed by the Screening Tool are 1) Living situation 2) Water leaks 3) Utilities 4) Financial strain 5) Family and Community Support 6) Education 7) Illegal Drugs 8) Mental Health 9) Disabilities. All of the above may impact the ability to perform dialysis at home, or a physicians likelihood to recommend and educate an individual about home dialysis. Intergenerational effects may influence many of these outcomes, particularly surrounding housing given lower wealth and home ownership among racial minorities.
2. Write a brief paragraph describing the extent to which a socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework?
While disparities in home dialysis use based on social risk factors have not been well described, racial and ethnic disparities have been shown in home dialysis use and outcomes. The below paper found that black patients had a 0.53 (0.50, 0.56) adjusted odds of home dialysis use and Hispanic patients had a 0.57 (0.53, 0.61) adjusted odds of home dialysis use. Their multivariable model, in addition to demographic and clinical characteristics, controlled for primary health insurance, which may be reflective of employment and poverty. Their model also included geographic location, which may be reflective of rurality and access to medical care. Their model also included cause of ESRD - there may be worse diagnosis in racial minorities or those with low socioeconomic status due to discrimination or barriers in accessing healthcare. Using a socioecological framework may have accounted for more variables such as income, education, or other social determinants, but these variables were likely not captured in the dataset. More efforts to collect this data and incorporate it in this type of research may lead to further understanding of mechanisms of disparities.Mehrotra R, Soohoo M, Rivara MB, Himmelfarb J, Cheung AK, Arah OA, Nissenson AR, Ravel V, Streja E, Kuttykrishnan S, Katz R. Racial and ethnic disparities in use of and outcomes with home dialysis in the United States. Journal of the American Society of Nephrology. 2016 Jul 1;27(7):2123-34.