Hilary Daniel, BS; Sue S. Bornstein, MD; Gregory C. Kane, MD; for the Health and Public Policy Committee of the American College of Physicians *
Financial Support: Financial support for the development of this position paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2441.
Requests for Single Reprints: Hilary Daniel, BS, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, email@example.com.
Current Author Addresses: Ms. Daniel: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Dr. Bornstein: 3111 Beverly Drive, Dallas, TX 75205.
Dr. Kane: Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107.
Author Contributions: Conception and design: H. Daniel, H.E. Gantzer, T.L. Henry, J.D. Lenchus, L. Viswanathan, A.M. Azah.
Analysis and interpretation of the data: H. Daniel, J.K. Carney, H.E. Gantzer, B.R. Nalitt, L. Viswanathan.
Drafting of the article: H. Daniel, G.C. Kane, J.D. Lenchus, B.M. McCandless.
Critical revision of the article for important intellectual content: H. Daniel, G.C. Kane, J.K. Carney, H.E. Gantzer, T.L. Henry, J.D. Lenchus, B.M. McCandless, L. Viswanathan, C.J. Murphy, A.M. Azah.
Final approval of the article: H. Daniel, S.S. Bornstein, G.C. Kane, J.K. Carney, H.E. Gantzer, T.L. Henry, J.D. Lenchus, J.M. Li, B.M. McCandless, B.R. Nalitt, L. Viswanathan, C.J. Murphy, A.M. Azah, L. Marks.
Administrative, technical, or logistic support: H. Daniel, S.S. Bornstein, G.C. Kane.
Collection and assembly of data: H. Daniel, T.L. Henry.
Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.
Appendix Table. Social Determinants of Health and Health Outcomes*
…an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelters) that provides temporary living accommodations, and an individual who is a resident in transitional housing. A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facility, abandoned building or vehicle; or in any other unstable or non-permanent situation.
…[look] at health from a broad perspective that considers social, economic, and environmental influences; [bring] community members, business interests and other stakeholders together, which can help build consensus; [acknowledge] the trade-offs of choices under consideration and [offer] decision makers comprehensive information and practical recommendations to maximize health gains and minimize adverse effects; [put] health concerns in the context of other important factors when making a decision; and [consider] whether certain impacts may affect vulnerable groups of people in different ways.
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James Webster MD, MS, MACP
Gertz Professor of Medicine Emeritus; Feinberg School of Medicine of NNorthwestern University
April 25, 2018
Helping Patients with the Adverse effects of Social Determants of Health
Social Determinants of Health
The recent ACP position paper (1) and editorial (2) focused on repairing the adverse effects of social determinants of health are indeed welcome. However, from a pragmatic standpoint they fall short in terms of concrete suggestions helping those in clinical care. These are huge impediments on the health of their patient in the examination room or hospital bed. This is especially a problem during a 15 minute office visit that already puts multiple requirements upon physicians. It is unreasonable to expect that they can also fix their patient’s serious social problems of this nature and magnitude.
I would suggest one solution; the delegation of these problems to medical social worker (MSW) colleagues. This is in the best interests of physicians, delivery system organizations and most importantly of patients. My own experience as a geriatric physician and solid national data (3) demonstrate that MSW’s are much better at problem solving for these issues for individual patients than are physicians and they are very “cost effective” with better health outcomes and greater patient satisfaction. MSW’s should be readily available for every practice no matter how organized. Hiring more of them to become part of the team is money well spent from every aspect.
1. Daniel H, Bornstein SS, Kane GC. Addressing social determinants to improve patient care and promote health equity : An American College of Physicians position paper. Ann Intern Med. 168;2018:577-78
2. Hammerstein DU, Woolhandler S. Determined action needed on social determinants. Ann Intern Med. 168;2018:596-97
3. Steketee G, Ross AM, Wachman MK. Health outcomes and costs of social work services: A systematic review. Am J Public Health. 2017(Suppl 3 ):S256-66
Martina Jelley, MD, MSPH, FACP
Department of Internal Medicine, University of Oklahoma School of Community Medicine
May 9, 2018
Ignoring childhood adversity in social determinants of health
I was pleased to see the ACP position paper on addressing the social determinants of health (SDH), as this has long been a neglected topic in internal medicine. But I was disappointed that the paper and accompanying appendix fail to mention what many consider to be a key social determinant of adult health – childhood trauma or adverse childhood experiences (ACEs). The paper begins with the World Health Organization definition of SDH, but fails to use the WHO specifics of SDH, which begins with “early years’ experiences”. (1) The ACP appears to be actively avoiding this topic. The evidence for a strong link between childhood adversity and adult health continues to grow since the Felitti and Anda landmark study published in 1998. (2) The ACE study revealed that childhood abuse, neglect, and household dysfunction are extremely prevalent and are strong risk factors for later deleterious health behaviors and negative health outcomes. ACEs risks are cumulative and affect mortality – for instance, a person with six or more categories of ACEs has a 20-year decrease in life expectancy as compared to a person with no ACEs. (3) An ACE score of 4 or more confers a significantly increased risk of heart disease, cancer, autoimmune disease, diabetes, substance abuse, mental illness, to name just a few of the 40+ conditions linked to ACEs by the CDC. (4) A trauma history also puts people at risk for other social determinants of health, including poverty and lower educational attainment. The neurobiology of trauma was not well understood at the time of the original study, but now there is a deepening body of knowledge about how brain development is affected by ACEs and how those effects can be reversed. (5) In trying to understand why this important category was ignored, it may be the viewpoint that childhood events don’t affect adult health. This has been the traditional stance in internal medicine. Standard medical history taking for an adult does not usually involve asking about childhood, unless there is a physical problem such as congenital heart disease. Another mindset may be a nihilistic attitude that nothing can be done for ACE-affected adults. Understanding how childhood trauma affects adult patients is the first step in helping them gain resilience and overcome the adversity from their past. The ACP should include childhood trauma in any future discussion of social determinants of health and help educate internists about this important topic.References:1. World Health Organization. World Conference on Social Determinants of Health, Rio Political Declaration on Social Determinants of Health 2011. Accessed at http://www.who.int/social_determinants/sdhconference/declaration/en/ on 9 April 2018.2. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 1998;14:245–258.3. Brown DW, Anda RA, Tiemeier H, Felitti VJ, Edwards VJ, Croft JB, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med. 2009;37(5):389-396.4. Centers for Disease Control. Adverse Childhood Experiences (ACEs). 2018. Accessed at https://www.cdc.gov/violenceprevention/acestudy/index.html on 9 April 2018.5. Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron 2016; 89:892-908.
Daniel H, Bornstein SS, Kane GC, for the Health and Public Policy Committee of the American College of Physicians. Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper. Ann Intern Med. 2018;168:577–578. doi: 10.7326/M17-2441
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Published: Ann Intern Med. 2018;168(8):577-578.
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