Neighborhood-level social determinants of health improve prediction of preventable hospitalization and emergency department visits beyond claims history

Chi, Winnie; Andreyeva, Elena; Zhang, Yongkang; Kaushal, Rainu; Haynes, Kevin

doi:10.1089/pop.2021.0047

Cited by 13Health disparities and outcomesMachine Learning in HealthcareHealthcare Policy and Management

Neighborhood-level social determinants of health improve prediction of preventable hospitalization and emergency department visits beyond claims history

Chi, Winnie, Andreyeva, Elena, Zhang, Yongkang, Kaushal, Rainu, Haynes, Kevin·2021·Population Health Management

DOI 10.1089/pop.2021.0047

Open this paper in CoChat — free account

Abstract

This study was conducted to assess if neighborhood-level social determinants of health improve model performance of predicting preventable hospitalization. Using medical and pharmacy claims and neighborhood-level social determinants and the split sample method (67% training with balanced sample and 33% validation), the authors developed prospective modeling for preventable hospital use, defined as hospitalization for ambulatory care sensitive conditions (Agency for Healthcare Research and Quality Prevention Quality Indicators 90 and 92) and preventable emergency department (ED) use (based on Billing's algorithm). Performance of age-gender only or age-gender with administrative claims models were compared to models with the addition of social determinants. Adding social determinants to age-gender only models and claim history models improves model performance as measured by Brier score, C statistics, and area under the precision-recall curve for preventable ED use measures while it leads to similar performance for predicting preventable hospital use compared to models without social determinants. Adding neighborhood-level social determinants improved prediction for preventable ED use in the absence of individual-level social determinants, regardless of the availability of full administrative claims history.

Integrity signals

Registry

Crossref · 10.1089/pop.2021.0047

Cites

31 of 31 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Claims the paper makes

This paper’s full text isn’t openly available, so its claims and self-check weren’t run. The registry and citation checks still apply.

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Models integrating both clinical and SDoH data may more effectively predict adverse events such as ED visits.
“Models integrating both clinical and SDoH data may more effectively predict adverse events such as ED visits [35–37].”
From Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health (2026) · cites this paper as [37]
These findings suggest that predictive modeling benefits from capturing both scales of SDoH, with area-level indices providing broad contextual signals and individual-level measures offering more actionable insights for tailoring case management interventions.
“These findings suggest that predictive modeling benefits from capturing both scales of SDoH, with area-level indices providing broad contextual signals and individual-level measures offering more actionable insights for tailoring case management interventions [33,36,37].”
From Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health (2026) · cites this paper as [37]
The integration of both area-level and individual-level SDoH goes beyond models relying solely on claims or areal-level indices.
“The integration of both area-level and individual-level SDoH goes beyond models relying solely on claims or areal-level indices [37]”
From Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health (2026) · cites this paper as [37]

Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization
Kind, A., Jencks, S., Brock, J., Yu, M., Bartels, C. M., Ehlenbach, W. J., Greenberg, C., & Smith, M. (2014) · Annals of Internal Medicine · doi:10.7326/m13-2946 · Cited by 1,383 · see citing works
Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter?: the Public Health Disparities Geocoding Project.
Krieger, N., Chen, J. T., Waterman, P. D., Soobader, M.-J., Subramanian, S., & Carson, R. (2002) · American Journal of Epidemiology · doi:10.1093/aje/kwf068 · Cited by 1,221 · see citing works
Impact Of Socioeconomic Status On Hospital Use In New York City
Billings, J., Zeitel, L., Lukomnik, J. E., Carey, T. S., Blank, A. E., & Newman, L. S. (1993) · Health Affairs · doi:10.1377/hlthaff.12.1.162 · Cited by 969 · see citing works
Housing instability and food insecurity as barriers to health care among low-income americans
Kushel, M., Gupta, R., Gee, L., & Haas, J. S. (2005) · Journal of General Internal Medicine · doi:10.1111/j.1525-1497.2005.00278.x · Cited by 843 · see citing works
Choosing area based socioeconomic measures to monitor social inequalities in low birth weight and childhood lead poisoning: The Public Health Disparities Geocoding Project (US)
Krieger, N., Chen, J. T., Waterman, P. D., Soobader, M.-J., Subramanian, S. V., & Carson, R. (2003) · Journal of Epidemiology & Community Health · doi:10.1136/jech.57.3.186 · Cited by 601 · see citing works
Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study
Kushel, M. B., Perry, S., Bangsberg, D., Clark, R., & Moss, A. R. (2002) · American Journal of Public Health · doi:10.2105/ajph.92.5.778 · Cited by 485 · see citing works
Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics
Weinick, R. M., Burns, R. M., & Mehrotra, A. (2010) · Health Affairs · doi:10.1377/hlthaff.2009.0748 · Cited by 451 · see citing works
Evaluating Area‐Based Socioeconomic Status Indicators for Monitoring Disparities within Health Care Systems: Results from a Primary Care Network
Berkowitz, S. A., Traore, C. Y., Singer, D. E., & Atlas, S. J. (2014) · Health Services Research · doi:10.1111/1475-6773.12229 · Cited by 291 · see citing works
Food insecurity, healthcare utilization, and high cost: a longitudinal cohort study.
Berkowitz, S. A., Seligman, H. K., Meigs, J. B., & Basu, S. (2018) · PubMed · Cited by 224 · see citing works
More May Be Better: Evidence of a Negative Relationship between Physician Supply and Hospitalization for Ambulatory Care Sensitive Conditions
Laditka, J. N., Laditka, S. B., & Probst, J. C. (2005) · Health Services Research · doi:10.1111/j.1475-6773.2005.00403.x · Cited by 200 · see citing works
Validation of an Algorithm for Categorizing the Severity of Hospital Emergency Department Visits
Ballard, D. W., Price, M., Fung, V., Brand, R., Reed, M., FIREMAN, B. H., Newhouse, J. P., Selby, J. V., & Hsu, J. T.-A. (2009) · Medical Care · doi:10.1097/mlr.0b013e3181bd49ad · Cited by 185 · see citing works
Current State of Value-Based Purchasing Programs
Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B. (2016) · Circulation · doi:10.1161/circulationaha.115.010268 · Cited by 178 · see citing works
The Use of Hospital Emergency Departments for Nonurgent Health Problems: A National Perspective
Cunningham, P. J., Clancy, C. M., Cohen, J. W., & Wilets, M. L. (1995) · Medical Care Research and Review · doi:10.1177/107755879505200402 · Cited by 173 · see citing works
Preventable Hospitalizations in Primary Care Shortage Areas: An Analysis of Vulnerable Medicare Beneficiaries
Parchman, M. L. (1999) · Archives of Family Medicine · doi:10.1001/archfami.8.6.487 · Cited by 173 · see citing works
Predictive modeling of U.S. health care spending in late life
Liran Einav, B., Finkelstein, A. N., Mullainathan, S., & Obermeyer, Z. (2018) · Science · doi:10.1126/science.aar5045 · Cited by 164 · see citing works
Primary Care, HMO Enrollment, and Hospitalization for Ambulatory Care Sensitive Conditions
Basu, J., Friedman, B., & Burstin, H. R. (2002) · Medical Care · doi:10.1097/00005650-200212000-00013 · Cited by 143 · see citing works
Disparities in Potentially Avoidable Emergency Department (ED) Care
Johnson, P. J., Ghildayal, N. S., Ward, A. C., Westgard, B. C., Boland, L. L., & Hokanson, J. S. (2012) · Medical Care · doi:10.1097/mlr.0b013e318270bad4 · Cited by 119 · see citing works
Trends In Avoidable Hospitalizations, 1980–1998
Kozak, L. J., Hall, M. J., & Owings, M. F. (2001) · Health Affairs · doi:10.1377/hlthaff.20.2.225 · Cited by 109 · see citing works
Hospitalization in an Urban Homeless Population: The Honolulu Urban Homeless Project
Martell, J. V., Seitz, R. S., Harada, J. K., Kobayashi, J., Sasaki, V. K., & Wong, C. (1992) · Annals of Internal Medicine · doi:10.7326/0003-4819-116-4-299 · Cited by 94 · see citing works
Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?
Fishman, J., McLafferty, S., & Galanter, W. (2016) · Health Services Research · doi:10.1111/1475-6773.12617 · Cited by 87 · see citing works
Predicting Potentially Avoidable Hospitalizations
Gao, J., Moran, E. A., Li, Y., & Almenoff, P. L. (2013) · Medical Care · doi:10.1097/mlr.0000000000000041 · Cited by 73 · see citing works
Costs Associated with Ambulatory Care Sensitive Conditions Across Hospital‐based Settings
Galarraga, J. E., Mutter, R. L., & Pines, J. M. (2015) · Academic Emergency Medicine · doi:10.1111/acem.12579 · Cited by 73 · see citing works
Emergency Room Use and Access to Primary Care: Evidence from Houston, Texas
Begley, C. E., Vojvodic, R. W., Seo, M., & Burau, K. D. (2006) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2006.0098 · Cited by 66 · see citing works
Using applied machine learning to predict healthcare utilization based on socioeconomic determinants of care
Chen, M. D. B. S. (2020) · The American Journal of Managed Care · doi:10.37765/ajmc.2020.42142 · Cited by 57 · see citing works
Neighborhood socioeconomic characteristics, healthcare spatial access, and emergency department visits for ambulatory care sensitive conditions for elderly
Huang, Y., Meyer, P. S., & Jin, L. (2018) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2018.08.015 · Cited by 37 · see citing works
Impact of Area Deprivation Index on the Performance of Claims-Based Risk-Adjustment Models in Predicting Health Care Costs and Utilization
Chang, H., Hatef, E., Ma, X., Weiner, J. P., & Kharrazi, H. H. K. (2020) · Population Health Management · doi:10.1089/pop.2020.0135 · Cited by 33 · see citing works
Ambulatory Care–Sensitive Condition Hospitalizations Among Medicare Beneficiaries
Lin, Y., Eberth, J. M., & Probst, J. C. (2016) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2016.05.005 · Cited by 32 · see citing works
Recognising potential for preventing hospitalisation
Banham, D., Woollacott, T., Gray, J., Humphrys, B., Mihnev, A., & McDermott, R. A. (2010) · Australian Health Review · doi:10.1071/ah09674 · Cited by 21 · see citing works
Enhancing Administrative Data to Predict Emergency Department Utilization: The Role of Neighborhood Sociodemographics
Lines, L. M., Rosen, A. B., & Ash, A. S. (2017) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2017.0129 · Cited by 20 · see citing works
Cost and Predictors of Hospitalizations for Ambulatory Care - Sensitive Conditions Among Medicaid Enrollees in Comprehensive Managed Care Plans
Mkanta, W. N., Chumbler, N. R., Yang, K., Saigal, R., & Abdollahi, M. (2016) · Health Services Research and Managerial Epidemiology · doi:10.1177/2333392816670301 · Cited by 19 · see citing works
Ambulatory Care Sensitive Hospitalizations Through the Emergency Department by Payer: Comparing 2003 and 2009
Dresden, S. M., Feinglass, J. M., Kang, R. H., & Adams, J. G. (2015) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2015.02.047 · Cited by 12 · see citing works

Flagged first, then by citations

Sorted by citations

Data Science Implementation Trends in Nursing Practice: A Review of the 2021 Literature
Wieben, A. M., Walden, R. L., Alreshidi, B. G., Brown, S., Cato, K., Coviak, C. P., Cruz, C., D’Agostino, F., Douthit, B. J., Forbes, T. H., et al. (2023) · Applied Clinical Informatics · doi:10.1055/a-2088-2893 · Cited by 11 · see citing works
Social Risk at Individual vs Neighborhood Levels and Health Care Use in Medicaid Enrollees
Knox, M. J., Tucher, E. L., Miller‐Rosales, C., McCloskey, J. K., Grant, R. W., & Iturralde, E. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.5047 · Cited by 7 · see citing works
Medicare Advantage Has Lower Resource Use and Better Quality of Care Than Traditional Medicare
Jung, J. K., Carlin, C., & Feldman, R. D. (2024) · American Journal of Health Economics · doi:10.1086/730436 · Cited by 6 · see citing works
Evaluating the Impact of Age and Comorbidities on COVID-19 Outcomes and Healthcare Costs: A Comparative Analysis of Immunocompromised and General Populations in the United States (EON-US)
Fang, C., Dobie, C., Ketkar, A. G., Verduzco‐Gutierrez, M., Fadda, G. Z., Bocage, C., Teng, C. C., Perez, R. A., Brunk-Grady, M., Glasser, L., et al. (2025) · Infectious Diseases and Therapy · doi:10.1007/s40121-025-01160-z · Cited by 4 · see citing works
Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States
Giannouchos, T. V., Ukert, B. D., Pirrallo, R. G., Smith, J., Kum, H., Wright, B., & Dietrich, A. M. (2023) · Academic Pediatrics · doi:10.1016/j.acap.2023.08.021 · Cited by 3 · see citing works
Contextual Determinants of Health Disparities in Utilization of Community-Based Rehabilitation Services Among Medicare Fee-for-Service Beneficiaries With Traumatic Brain Injury
Onwudebe, C. K., Aguirre, C. R., Malagaris, I., Kuo, Y., & Pappadis, M. R. (2025) · Journal of Head Trauma Rehabilitation · doi:10.1097/htr.0000000000001026 · Cited by 2 · see citing works
Identify Social Determinants of Health Related to Ambulatory Care Sensitive Conditions: Decreasing Hospitalizations and Emergency Department Visits
Gjini, M., Khan, N., Vuljaj, G., Stefanovski, A., Kaminski, A., Weber, B., & Dean, C. A. (2022) · Research Directs in Health Sciences · doi:10.53520/rdhs2022.10428 · Cited by 1 · see citing works
Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health
Lee, S.-Y., Saleem, M., Land, A. M., DeLaney, E. W., Garretson, A. R., Patel, M., Hall, A. G., Westrick, S., Ovalle, F., Cherrington, A. L., et al. (2026) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2026.106604
Association Between Insurer Connectivity in Appalachian Population Health Networks and Preventable Hospitalizations
Hogg‐Graham, R., Gatton, K., Ingram, R., & Mays, G. P. (2024) · PubMed Central · doi:10.13023/jah.0502.03
Longitudinal Trends in Insurer Participation in Multisector Population Health Activities
Hogg‐Graham, R., Waters, T. M., Clear, E. R., Pearson, K., Benitez, J. A., & Mays, G. P. (2024) · INQUIRY The Journal of Health Care Organization Provision and Financing · doi:10.1177/00469580241249092
Risk Stratification for Post-Hospitalization Case Management in Diabetes: Integrating Clinical and Socioeconomic Data (Preprint)Preprint
Lee, S.-Y., Saleem, M., Land, A. M., Delaney, E. W., Garretson, A., Patel, M., Hall, A. G., Westrick, S. C., Ovalle, F., Cherrington, A., et al. (2025) · doi:10.2196/preprints.72624
Impact of social determinants of health on treatment patterns and outcomes in metastatic non-small cell lung cancer
Hill, N. R., Crosbie, A., Szymialis, R., Botros, A., Zhang, Y., & Tapan, Ü. (2026) · Journal of Oncology Pharmacy Practice · doi:10.1177/10781552261449764
Self-citation
Structural awareness and knowledge of social determinants among pharmacists by practice settings and training eras
Okoro, O. N., & MPH (2026) · Currents in Pharmacy Teaching and Learning · doi:10.1016/j.cptl.2026.102803

Assessing the impact of social determinants of health on predictive models for potentially avoidable 30-day readmission or death
Zhang, Y., Zhang, Y., Sholle, E., Abedian, S., Sharko, M., Turchioe, M. R., Wu, Y., & Ancker, J. S. (2020) · PLoS ONE · doi:10.1371/journal.pone.0235064 · Cited by 57 · see citing works
Self-citation
Assessing performance of ZCTA-level and Census Tract-level social and environmental risk factors in a model predicting hospital events
Goetschius, L. G., Henderson, M. A., Han, F., Mahmoudi, D., Perman, C., Haft, H., & Stockwell, I. (2023) · Social Science & Medicine · doi:10.1016/j.socscimed.2023.115943 · Cited by 9 · see citing works
Prediction of emergency department revisits using area-level social determinants of health measures and health information exchange information
Vest, J. R., & Ben-Assuli, O. (2019) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2019.06.013 · Cited by 61 · see citing works
Assessing the Capacity of Social Determinants of Health Data to Augment Predictive Models Identifying Patients in Need of Wraparound Social Services
Kasthurirathne, S. N., Vest, J. R., Menachemi, N., Halverson, P. K., & Grannis, S. J. (2018) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocx130 · Cited by 71 · see citing works
Assessment of Value of Neighborhood Socioeconomic Status in Models That Use Electronic Health Record Data to Predict Health Care Use Rates and Mortality
Schuler, A., O’suilleabhain, L., Rinetti-Vargas, G., Kipnis, P., Barreda, F. X., Liu, V. X., Sofrygin, O., & Escobar, G. J. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.17109 · Cited by 17 · see citing works

Authors: Chi, W., Andreyeva, E., Zhang, Y., Kaushal, R., & Haynes, K.
Affiliations: Carelon Research (United States) (US)
Weill Cornell Medicine (US)
NewYork–Presbyterian Hospital (US)
Corresponding author: Chi, Winnie
ORCID: Chi, Winnie
Andreyeva, Elena
Zhang, Yongkang
Kaushal, Rainu
Haynes, Kevin
Venue: Population Health Management
Publisher: SAGE Publications
Published: 2021-12
Volume: 24
Issue: 6
Pages: 701-709
ISSN: 1942-7891 (ISSN-L)
1942-7905
DOI: 10.1089/pop.2021.0047
OpenAlex: W3161463361
Cited by: 13
References: 31
Citations by year: 2026: 3 · 2025: 4 · 2024: 3 · 2023: 2 · 2022: 1
FWCI: 0.83
Type: journal article
Language: en
Open access: closed
Licence: journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations: Population Health Management (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Health › Health disparities and outcomes
Physical Sciences › Computer Science › Artificial Intelligence › Machine Learning in Healthcare
Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Keywords: social determinants of health, avoidable hospitalizations, ambulatory care sensitive conditions, hospital readmission prediction, prediction model performance
MeSH terms: Ambulatory Care Sensitive Conditions, Emergency Service, Hospital, Hospitalization, Humans, Prospective Studies, Social Determinants of Health

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review

Neighborhood-level social determinants of health improve prediction of preventable hospitalization and emergency department visits beyond claims history

Abstract

Integrity signals

Claims the paper makes

Claims other papers make about this one

Cites

Cited by

Related

Record

About these checks