Social Determinants of Health Screening in a Pediatric Asthma Population Leveraging an Institutional Electronic Medical Record-based Population Registry

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Abstract Rationale Understanding family experience for social determinants of health (SDOH), like neighborhood factors and financial constraints, supports comprehensive asthma care delivery. In 2021, our institution implemented an annual, electronic medical record (EMR)-based SDOH screen for clinic patients across four risk domains: housing, financial security, nutrition needs, and transportation. To support development of an intensive asthma clinic, we aimed to describe SDOH screening and its population reach in an EMR-defined asthma registry and to determine an association between positive SDOH screening and increased emergency department (ED) visits or hospitalizations. Methods We created a registry using EPIC Healthy Planet, a population management software module that collates EMR-available data including demographics, language of care (LOC), and SDOH screening results and linked to Childhood Opportunity Index (COI) based on zip code. The registry was set to include patients with an EMR asthma diagnosis, albuterol prescription, and at least one ED, urgent care, or inpatient admission in the past year. We used descriptive statistics to summarize registry population characteristics and responses to SDOH screening. Negative binomial regression modeled associations between ED visits/hospitalizations, sociodemographic factors, and SDOH screening. For race and ethnicity, we used a weighted population mean as a reference. We calculated odds ratios to identify gaps in screening by sociodemographic factors. Results Of 4,694 registry patients, patients identified commonly as Asian (12%), Black (10%), Hispanic (23%), and white (34%); 48% were missing SDOH screens. The odds [95% CI] of receiving SDOH screening was higher among families with Spanish LOC (1.38 [1.09, 1.75]) and public insurance (1.30 [1.15, 1.47]), but lower among Asian patients (0.67 [0.58, 0.79]) and those with non-English, non-Spanish LOC (0.37 [0.26, 0.52]).Of 2,464 (52%) registry patients who completed SDOH screening, 1,040 (42%) endorsed any risk factor with the most frequent being financial needs (N=815). Positive screens were more likely among patients with public insurance, Spanish or other non-English LOC, identified as Black/African American, Hispanic, or with a lower COI. There was no significant association between positive SDOH screening results and increased ED visits or hospitalizations. Conclusions We leveraged an EMR-based population registry to highlight prevalent social risks among children with asthma and across intersecting sociodemographic domains, and identified screening gaps such as those with non-English/Spanish LOC. Our findings can inform future tailored resources to identify and address social risks. A learning system, integrating EMR-based registry and service design may be a powerful approach to enhance equitable asthma care delivery.

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