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Introduction/Objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community organizations for assistance. Understanding how social determinants cluster together may help guide assistance programs. Methods: This study examined patients screened by The MetroHealth System in Cleveland, Ohio for 9 social determinants, including food insecurity, financial strain, transportation limitations, inability to pay for housing or utilities, intimate partner violence, social isolation, infrequent physical activity, daily stress, and lack of internet access. Clustering analyses were performed to determine which combination of social determinants occurred together more often than would be expected if each determinant were independent of each other. Results: Among 23 161 screened patients, there were 19 dyads, 13 triads, and one tetrad of social determinants that clustered together. The most prevalent triad of food insecurity, social isolation, and inability to pay for housing or utilities occurred among 1095 patients but would be expected to occur among 284 patients, for an observed/expected ratio of 3.85 (95% confidence interval 3.64-4.07). In multivariate analyses, younger, Black, and lower income patients were 2 to 3 times more likely to have this triad compared to older, White, and wealthier patients. Conclusions: Social determinants of health frequently cluster together, and such clustering is associated with patient demographic characteristics. Further work is needed to determine how social determinant clusters impact health and cost outcomes and to develop programs that can address multiple co-existing social needs. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. However, little is known about social determinants of health among health system employees. We sought to examine the prevalence of social determinants among employees of The MetroHealth System, a large safety-net health system in Cleveland, Ohio. Methods: We invited participants in an employee wellness program to answer the same screening questions that patients answer about 9 social determinants of health, including food insecurity, financial strain, transportation difficulty, inability to pay for housing or utilities, intimate partner violence, social isolation, infrequent physical activity, daily stress, and lack of internet access. We then determined the percentage of employees who met pre-defined criteria for being at risk for each social determinant. We also examined how these percentages varied across employee job categories. Results: Of 4191 full-time employees, 1932 (46%) completed the survey. The percentage of employees at risk for each social determinant were: food insecurity (11%), financial strain (12%), transportation difficulty (4%), inability to pay for housing or utilities (10%), intimate partner violence (4%), social isolation (48%), infrequent physical activity (10%), daily stress (58%), and lack of internet access (3%). Being at risk for specific social determinants was more common among support staff compared to staff physicians and nurses. For example, the survey participants included 436 administrative support staff, a job category that includes secretaries and patient service representatives. Among this group, 20% reported food insecurity, 20% financial strain, and 17% inability to pay for housing or utilities. Conclusions: Social determinants of health are common among health system employees, especially among workers in lower paid job categories. Health systems should routinely screen employees for social determinants and adjust salaries, benefits, and assistance programs to address their social needs. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. We developed a framework based on sequential steps to evaluate this process. Methods: We reviewed efforts by The MetroHealth System in Cleveland, Ohio and identified 6 sequential steps: patient screened, has social needs, consents to referral to a service organization, referral placed, referral accepted, and referral outcome. Referral outcomes were categorized as resolved (organization provided requested service or patient self-resolved problem), or unresolved (patient unable to be contacted or declined assistance). We then determined the numbers of patients with food insecurity who completed each step, how completion differed by patient characteristics and service organization, and reasons for failure to complete specific steps. Results: We used the framework to evaluate screening and assistance steps among 5741 patients who attended a COVID-19 vaccine clinic from February 15-March 31, 2021 and were followed through April 30, 2021. The percentage of patients who completed each step ranged from 17-98%. Step completion differed by patient age, patient race, and clinic. Of 360 referrals accepted by community organizations, 98 (27%) were resolved. The most common reasons for unresolved referrals were inability of service organization to contact patients (151), no reason stated (71), and patients declined service (30). Conclusions: A framework based on sequential steps may be used to evaluate social determinants of health screening and assistance programs. Further work is needed to address reasons for failure to complete steps, to include patient perspectives, and to determine long-term outcomes. [ABSTRACT FROM AUTHOR]

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers. [ABSTRACT FROM AUTHOR]

Introduction: Organ donation and other altruistic behaviors may be influenced by multiple factors, such as demographic characteristics, religious beliefs, and social norms. Research Question: What is the role of genetic factors on altruism in identical and fraternal twin pairs? Design: Twins attending a twin festival (N = 296) completed an organ donation and altruistic behavior survey. Results: Concordance for stage of change for organ donation was 65% among identical twin pairs versus 33% among fraternal twin pairs (P =.004). Concordance was higher among identical versus fraternal twin pairs for several altruistic behaviors, including giving directions to a stranger (63% vs 24%, P <.001), giving money to a stranger (51% vs 29%, P =.048), donating goods to charity (46% vs 16%, P =.005), and offering a seat on the bus (46% vs 24%, P =.04). Discussion: We conclude that genetic factors may play a role in decisions about organ donation and other altruistic behaviors. [ABSTRACT FROM AUTHOR]

Neighborhoods affect health. In 3 adjoining inner-city Cleveland, Ohio, neighborhoods, residents have an average life expectancy 15 years less than that of a nearby suburb. To address this disparity, a local health funder created the 2010 to 2013 Francis H. Beam Community Health Fellowship to develop a strategic community engagement process to establish a Healthy Eating & Active Living (HEAL) culture and lifestyle in the neighborhoods. The fellow developed and advanced a model, engaging the community in establishing HEAL options and culture. Residents used the model to identify a shared vision for HEAL and collaborated with community partners to create and sustain innovative HEAL opportunities. This community-led, collaborative model produced high engagement levels (15% of targeted 12000 residents) and tangible improvements in the neighborhood's physical, resource, and social environments. [ABSTRACT FROM AUTHOR]

Background: The efficacy of video interventions to increase organ donation willingness remains unclear. Methods: Three‐arm web‐based randomized controlled trial involving 2261 students at 3 northeastern Ohio universities. Intervention students watched a live‐action (n = 755) or animated (n = 753) donation video. Control students (n = 753) viewed wellness information from the Centers for Disease Control and Prevention (CDC). The primary outcome was proportion of students who visited their state electronic donor registry to consent. The secondary outcome was intervention quality. Logistic regression assessed the effects of interventions on visiting the state registry to provide donation consent while controlling for baseline variables. Results: Students in the live‐action video arm visited their state registry more frequently than students in the CDC arm (OR = 1.86, 95% CI = 1.20‐2.88). There was no difference between students in the animated video and CDC arms (OR = 1.10, 95% CI = 0.69‐1.76). The quality of the live‐action video was rated lower than the animated video and the CDC text (75% ± 18, 84% ± 16, 80% ± 16, respectively; P < 0.001). Conclusion: Students who watched the live‐action video were more willing to visit their electronic donor registry to register as organ donors, but rated it lower in satisfaction. Future work should identify the most potent components of organ donation interventions. [ABSTRACT FROM AUTHOR]

Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality. The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts. A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments. Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH. HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research. Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P <0.05 and P <0.10 because of modest sample sizes in each community. Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (β=.295, Cleveland; β=.297, Columbus, P <0.05) and distance traveled to primary food store (β=.111, Cleveland, P <0.10; β=.175, Columbus, P <0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (β=−.125, P <0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R 2=.282 and R 2=.152, respectively). Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away. [ABSTRACT FROM AUTHOR]

This descriptive study examines the prevalence of comorbid physical and mental health issues among young clients at a large mental health agency. Health status data was collected from the intake process of youth seeking mental health services at a Northeast Ohio agency (n = 1,076). The results show a higher prevalence of asthma and obesity among clients with known mental health diagnoses at this agency compared to national averages. The results could help the agency develop strategies for implementation of an integrated care model to better meet the complex needs of the clients served. [ABSTRACT FROM AUTHOR]

Background: Screening for depression can be challenging among hemodialysis patients due to the overlap of depressive symptoms with dialysis or kidney disease related symptoms. The aim of this study was to understand these overlapping symptoms and develop a depression screening tool for better clinical assessment of depressive symptoms in dialysis patients., Methods: We surveyed 1,085 dialysis patients between March 1, 2018 and February 28, 2023 at 15 dialysis facilities in Northeast Ohio with the 9-item patient health questionnaire (PHQ-9) and kidney disease quality of life (KDQOL) instrument. To evaluate overlap across questionnaire items, we used structural equation modeling (SEM). We predicted and transformed factor scores to create a hemodialysis-adjusted PHQ-9 (hdPHQ-9). In exploratory analysis ( N  = 173), we evaluated the performance of the hdPHQ-9 relative to the PHQ-9 that also received a Mini-International Neuropsychiatric Interview., Results: Our study sample included a high percentage of Black patients (74.6%) and 157 (14.5%) survey participants screened positive for depression (PHQ-9 ≥ 10). The magnitude of overlap was small for (respectively, PHQ-9 item with KDQOL TM item) fatigue with washed out, guilt with burden on family, appetite with nausea and movement with lightheaded. The hdPHQ-9 showed reasonably high sensitivity (0.81 with 95% confidence interval [CI] 0.58, 0.95) and specificity (0.84 with 95% CI 0.77, 0.89); however, this was not a significant improvement from the PHQ-9., Conclusion: There is little overlap between depressive symptoms and dialysis or kidney disease symptoms. The PHQ-9 was found to be an appropriate depression screening instrument for dialysis patients.

Background: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and use systems that effectively manage the demand for services., Methods: This was a cohort study using electronic health records at a health care system in northeast Ohio that examined the effectiveness of the first 5 weeks of a 24/7 physician-staffed COVID-19 hotline including social care referrals for patients required to self-isolate. We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing., Participants: In 5 weeks, 10,112 patients called the hotline (callers). Of these, 4213 (42%) were referred for a physician telehealth visit (telehealth patients). Mean age of callers was 42 years; 67% were female, 51% white, and 46% were on Medicaid/uninsured., Results: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 patients (7%) had a subsequent emergency department visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported, with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency department use (odds ratio = 4.73, 95% confidence interval = 1.37-16.39, P = .014). Only older age was associated with having a positive test result. Patients with social needs and interest in receiving help were offered services to meet their needs including food deliveries (n = 92), behavioral health telephone visits (n = 49), and faith-based comfort calls from pastoral care personnel (n = 37)., Conclusions and Relevance: Robust, physician-directed telehealth services can meet a wide range of clinical and social needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers., (© Copyright 2021 by the American Board of Family Medicine.)

Objective: The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian., Methods: This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others)., Results: The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94)., Conclusion: About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to determine the prevalence of phosphorus-containing food additives in best-selling processed grocery products and to compare the phosphorus content of a subset of top-selling foods with and without phosphorus additives., Design: The labels of 2394 best-selling branded grocery products in northeast Ohio were reviewed for phosphorus additives. The top 5 best-selling products containing phosphorus additives from each food category were matched with similar products without phosphorus additives and analyzed for phosphorus content. Four days of sample meals consisting of foods with and without phosphorus additives were created, and daily phosphorus and pricing differentials were computed., Main Outcome Measures: Presence of phosphorus-containing food additives, phosphorus content., Results: Forty-four percent of the best-selling grocery items contained phosphorus additives. The additives were particularly common in prepared frozen foods (72%), dry food mixes (70%), packaged meat (65%), bread and baked goods (57%), soup (54%), and yogurt (51%) categories. Phosphorus additive-containing foods averaged 67 mg phosphorus/100 g more than matched nonadditive-containing foods (P = .03). Sample meals comprised mostly of phosphorus additive-containing foods had 736 mg more phosphorus per day compared with meals consisting of only additive-free foods. Phosphorus additive-free meals cost an average of $2.00 more per day., Conclusion: Phosphorus additives are common in best-selling processed groceries and contribute significantly to their phosphorus content. Moreover, phosphorus additive foods are less costly than phosphorus additive-free foods. As a result, persons with chronic kidney disease may purchase these popular low-cost groceries and unknowingly increase their intake of highly bioavailable phosphorus., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Many patients with ESRD, particularly minorities and women, face barriers in completing the steps required to obtain a transplant. These eight sequential steps are as follows: medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on completion of steps., Design, Setting, Participants, & Measurements: Cluster randomized, controlled trial at 23 Ohio hemodialysis facilities. One hundred sixty-seven patients were recruited between January 2009 and August 2009 and were followed for up to 24 months or until study end in February 2011. Trained kidney transplant recipients met monthly with intervention participants (n=92), determined their step in the transplant process, and provided tailored information and assistance in completing the step. Control participants (n=75) continued to receive usual care. The primary outcome was the number of transplant process steps completed., Results: Starting step did not significantly differ between the two groups. By the end of the trial, intervention participants completed more than twice as many steps as control participants (3.5 versus 1.6 steps; difference, 1.9 steps; 95% confidence interval, 1.3-2.5 steps). The effect of the intervention on step completion was similar across race and sex subgroups., Conclusions: Use of trained transplant recipients as navigators resulted in increased completion of transplant process steps.

Background: The objective of this study was to determine whether health care disparities exist in management of Graves' disease., Methods: Patients treated for Graves' disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data., Results: A total of 634 patients were treated for Graves' disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001)., Conclusions: A disproportionate number of uninsured patients underwent thyroidectomy for Graves' disease. Social and economic factors may have a role in determining definitive therapy for Graves' disease., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The gap between the supply of organs available for transplantation and demand is growing, especially among ethnic groups., Objective: To evaluate the effect of a video designed to address concerns of ethnic groups about organ donation., Design: Cluster randomized, controlled trial. Randomization was performed by using a random-number table with centralized allocation concealment. Participants and investigators assessing outcomes were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00870506), Setting: Twelve branches of the Ohio Bureau of Motor Vehicles in northeastern Ohio., Participants: 952 participants aged 15 to 66 years., Intervention: Video (intervention; n = 443) or usual Bureau of Motor Vehicles license practices (control; n = 509)., Measurements: The primary outcome was the proportion of participants who provided consent for organ donation on a newly acquired driver's license, learner's permit, or state identification card. Secondary outcomes included willingness to make a living kidney donation to a family member in need and personal beliefs about donation., Results: More participants who viewed the video consented to donate organs than control participants (84% vs. 72%; difference, 12 percentage points [95% CI, 6 to 17 percentage points]). The video was effective among black participants (76% vs. 54%; difference, 22 percentage points [CI, 9 to 35 percentage points]) and white participants (88% vs. 77%; difference, 11 percentage points [CI, 5 to 15 percentage points]). At the end of the trial, fewer intervention than control participants reported having insufficient information about organ donation (34% vs. 44%; difference, -10 percentage points [CI, -16 to -4 percentage points]), wanting to be buried with all of their organs (14% vs. 25%; difference, -11 percentage points [CI, -16 to -6 percentage points]), and having conflicts with organ donation (7% vs. 11%; difference, -4 percentage points [CI, -8 to -2 percentage points])., Limitation: How the observed increases in consent to donate organs might translate into a greater organ supply in the region is unclear., Conclusion: Exposure to a brief video addressing concerns that ethnic groups have about organ donation just before obtaining a license, permit, or identification card increased consent to donate organs among white and black participants., Primary Funding Source: National Institutes of Health and the Robert Wood Johnson Foundation.

Background: The amount of hemodialysis that patients receive is an independent predictor of mortality. However, the relative predictive ability of four common measures of dialysis dose (urea reduction ratio, single-pool Kt/V, double-pool Kt/V, and urea index) is unclear., Methods: Using The Renal Network Data System, we identified 14,810 incident hemodialysis patients in Indiana, Kentucky, Ohio, and Illinois from 1997 to 2000. We calculated each measure of hemodialysis dose during the first 6 months of treatment, then prospectively followed up patients for an additional 6 months. For each measure of dialysis dose, we developed a logistic regression model to examine the relationship between dose and patient mortality after adjustment for age, race, sex, cause of renal failure, comorbid conditions, and albumin level. We compared the predictive ability of the four models using the c statistic, a measure of how frequently survivors have a lower predicted probability of death compared with nonsurvivors. C statistics can vary from 0.50 (no predictive ability) to 1.00 (perfect predictive ability)., Results: Of all patients, 11.3% died during follow-up. Mortality was independently associated with low dialysis dose, advanced age, white race, female sex, specific comorbid conditions, and low albumin level. All four predictive models had virtually identical c statistics (range, 0.69 to 0.70)., Conclusion: Models including hemodialysis dose and patient characteristics have a modest ability to predict mortality. Moreover, all four measures of dialysis dose have an equivalent predictive ability. Decisions to use a specific measure should be based on other considerations, such as ease of use, need to troubleshoot inadequate dialysis delivery, or research on urea kinetics or nutritional factors., (Copyright 2002 by the National Kidney Foundation, Inc.)

Background: Kidney transplantation rates differ by patient and dialysis-facility characteristics, yet little is known about the sources of this variation or how access to transplantation can be improved. Examining specific steps in the transplantation process may guide quality improvement efforts that ultimately improve the equity and efficiency of transplantation., Methods: We sought to examine variation across dialysis facilities in the completion of four specific steps (medical suitability, interest in transplantation, pretransplantation workup, and waiting list) after adjustment for patient characteristics. Using 11,674 patients on chronic hemodialysis therapy between January 1993 and December 1996 at 206 facilities in Indiana, Kentucky, and Ohio, we derived facility-specific: (1) actual completion rates at each step; (2) expected completion rates based on patient age, race, sex, and cause of renal failure; and (3) ratio of actual to expected completion rates., Results: Actual completion rates varied greatly, with facilities at the 75th percentile having a twofold greater completion rate than facilities at the 25th percentile (eg, 59% versus 32% at the first step). Although patient characteristics were strongly associated with step completion, adjustment for these characteristics did not decrease variation across facilities. At each step, approximately 20% of facilities had a significantly greater than expected completion rate, whereas approximately 15% had a significantly lower than expected completion rate., Conclusion: There is substantial variation across dialysis facilities in access to kidney transplantation, even after adjustment for patient characteristics. Identifying steps with less than expected completion rates may help facilities target such efforts as treatment of medical conditions, patient education, and early referral for pretransplantation workup and waiting list placement., (Copyright 2002 by the National Kidney Foundation, Inc.)