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Cited by 4Food Security and Health in Diverse PopulationsHealth disparities and outcomesHomelessness and Social Issues

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Predicting Self‐Reported Social Risk in Medically Complex Adults Using Electronic Health Data

Grant, Richard W., McCloskey, Jodi K., Uratsu, Connie S., Ranatunga, Dilrini, Ralston, James D., Bayliss, Elizabeth A., Sofrygin, Oleg·2024·Medical Care
DOI 10.1097/mlr.0000000000002021
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Abstract

Background Social barriers to health care, such as food insecurity, financial distress, and housing instability, may impede effective clinical management for individuals with chronic illness. Systematic strategies are needed to more efficiently identify at-risk individuals who may benefit from proactive outreach by health care systems for screening and referral to available social resources. Objective To create a predictive model to identify a higher likelihood of food insecurity, financial distress, and/or housing instability among adults with multiple chronic medical conditions. Research design and subjects We developed and validated a predictive model in adults with 2 or more chronic conditions who were receiving care within Kaiser Permanente Northern California (KPNC) between January 2017 and February 2020. The model was developed to predict the likelihood of a "yes" response to any of 3 validated self-reported survey questions related to current concerns about food insecurity, financial distress, and/or housing instability. External model validation was conducted in a separate cohort of adult non-Medicaid KPNC members aged 35-85 who completed a survey administered to a random sample of health plan members between April and June 2021 (n = 2820). Measures We examined the performance of multiple model iterations by comparing areas under the receiver operating characteristic curves (AUCs). We also assessed algorithmic bias related to race/ethnicity and calculated model perfo…

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Metadata

Authors
Grant, R. W., McCloskey, J. K., Uratsu, C. S., Ranatunga, D., Ralston, J. D., Bayliss, E. A., & Sofrygin, O.
Affiliations
  • Kaiser Permanente (US)
  • Kaiser Permanente Washington Health Research Institute (US)
Corresponding author
  • Grant, Richard W.
  • McCloskey, Jodi K.
  • Uratsu, Connie S.
  • Ranatunga, Dilrini
  • Sofrygin, Oleg
ORCID
Venue
Medical Care
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2024-06-04
Volume
62
Issue
9
Pages
590-598
ISSN
0025-7079 (ISSN-L)
DOI
10.1097/mlr.0000000000002021
OpenAlex
W4399332215
Cited by
4
References
52
Citations by year
2026: 2 · 2025: 2
FWCI
2.33
Type
journal article
Language
en
Open access
closed
Locations
  • Medical Care (publishedVersion)
  • PubMed (publishedVersion)
Funders
Agency for Healthcare Research and Quality (R18 HS027343)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Food Security and Health in Diverse Populations
  • Social Sciences › Health › Health disparities and outcomes
  • Social Sciences › Sociology and Political Science › Homelessness and Social Issues
Keywords
social determinants of health, food insecurity, financial distress, housing instability, multimorbidity, prediction model, algorithmic bias, race and ethnicity, social needs screening, Kaiser Permanente, electronic health data, census tract data
MeSH terms
Food Insecurity, Financial Stress, Adult, Aged, Aged, 80 and over, California, Chronic Disease, Female, Humans, Male, Middle Aged, Risk Assessment, Electronic Health Records, Self Report

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