Evidence map›Paper›PMID 39289288›Full record

ArticleJournal of general internal medicine2024

Addressing Social Determinants of Health in Primary Care Patients May Reduce Hospital Readmissions: A Quasi-Experimental Study.

Jungyoon Kim, Hongmei Wang, Jihyun Ma, Daniel Jeffrey, Stephen Mohring, April Recher, Jane F Potter

Abstract read
PubMed Full text at PMC Publisher
In one paragraph

Article in Journal of general internal medicine, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.

0numbers the graph read from it
0cells of the map it votes in
5citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

5 citing papers in PubMed.

  1. Trial
  2. Rethinking early follow-up: Lessons from SILVER-AMI.Journal of hospital medicine · 2026
    Article
  3. Article
  4. Article
  5. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

7 authors.

Jungyoon KimDepartment of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA. Jungyoon.kim@unmc.edu.ORCID 0000-0002-2945-2460
Hongmei WangDepartment of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.
Jihyun MaDepartment of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.
Daniel JeffreyDepartment of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
Stephen MohringDepartment of Internal Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
April RecherNebraska Medicine, Omaha, NE, USA.
Jane F PotterDepartment of Internal Medicine, Division of Geriatrics, Gerontology and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE, USA.

Funding

HRSA HHS U1QHP33079
6 · The paper itself

Abstract

backgroundHealth care systems are increasingly partnering with community-based organizations to address social determinants of health (SDH). We established a program that educates and connects patients with SDH needs at a primary care clinic to community services and facilitated referrals.

objectiveTo evaluate the effect of addressing SDH soon after discharge on hospital readmission in a clinic population.

designPre/post, quasi-experimental design with longitudinal data analysis for quality improvement.

participantsClinic patients (n = 754) having at least one hospital discharge between June 1, 2020, and October 31, 2021, were included. Of these, 145 patients received the intervention and 609 served as comparison.

interventionsA primary care liaison was employed to assess and educate recently discharged clinic patients for SDH needs and refer them for needed community services from June 1, 2020, to October 31, 2021. MAIN MEASURES: Hospital readmissions within 30, 60, and 90 days of discharge were tracked at 6-month intervals. Covariates included patient age, sex, race/ethnicity, insurance status, income, Hierarchical Condition Category risk scores, and Clinical Classification Software diagnosis groups. Data for all hospital discharges during the intervention period were used for the main analysis and data for the year before the intervention were extracted for comparison. KEY

resultsOverall, patients in the intervention group were older, sicker, and more likely to have public insurance. The reductions in 30-, 60-, and 90-day readmissions during the intervention period were 14.39%, 13.28%, and 12.04% respectively in the intervention group, while no significant change was observed in the comparison group. The group difference in reduction over time was statistically significant for 30-day (Diff = 12.54%; p = 0.032), 60-day (Diff = 14.40%; p = 0.012), and 90-day readmissions (Diff = 14.71%; p = 0.036).

conclusionOur findings suggest that screening clinic patients for SDH, and educating and connecting them to community services during post-hospital care may be associated with reductions in hospital readmissions.

Indexed as

Patient ReadmissionPrimary Health CareSocial Determinants of HealthAdultAgedFemaleHumansLongitudinal StudiesMaleMiddle AgedPatient Dischargecommunity-based serviceshospital readmissionprimary caresocial determinants of health

Identifiers

PMID39289288
PMCPMC11618550

What OpenQuestion holds

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.