Impact of Social Risk Decision Support
Improving Population and Clinical Health With Integrated Services and Advanced Analytics
Study Overview
Status
Status
Conditions
Conditions
Intervention / Treatment
Intervention / Treatment
Detailed Description
Social determinant of health related needs and social risk factors complicate care delivery and drive health and well-being. Social needs are common among undeserved patient populations, but health care providers are often not equipped to routinely identify and address patients in need.
Using a combination of health information exchange, electronic health record, and aggregate datasets the investigators developed predictive algorithms to identify patients a highest risk for a need for a referral to a social worker, dietitian, behavioral health, or other wraparound service provider. Risk scores are available to primary care providers in two ways within the electronic health record system (EHR): 1) a graphical summary of individual risk or 2) a line listing of all scheduled patients.
The investigators are introducing the risk-stratification tool in an urban safety-net primary care provider on a voluntary usage basis.
Study Type
Study Type
Phase
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Indiana
-
Indianapolis, Indiana, United States, 46202
- Eskenazi Health
-
-
Participation Criteria
Eligibility Criteria
Eligibility Criteria
Ages Eligible for Study
- Child
- Adult
- Older Adult
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Encounters among patients seeking primary care service at any of the 9 Eskenazi Health FQHC clinics in Indianapolis, IN from January 2017 to May 2020.
- The propensity score matched primary care encounters from non-Eskenazi facilities.
Exclusion Criteria:
- Emergency encounters or hospitalizations
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Screening
- Allocation: Non-Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Number of Arms
Arms and Interventions
Participant Group / ArmParticipant Group / Arm |
Intervention / TreatmentIntervention / Treatment |
|---|---|
|
Experimental: Intervention group
Encounters at primary care clinics with the risk screening tool
|
Risk screening tool is available to providers
|
|
No Intervention: Comparison group
Propensity score matched comparison encounters
|
What is the study measuring?
Primary Outcome Measures
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
ED utilization rate
Time Frame: 6 months
|
Rate of potentially avoidable emergency department utilization as determined by encounters recorded in health information exchange data and categorized using the NYU ED Algorithm.
|
6 months
|
|
Missed primary care appointments rate
Time Frame: 6 months
|
Rate of no show / cancelled appointments at the intervention site primary care clinics as recorded in the intervention site's electronic health record system
|
6 months
|
Secondary Outcome Measures
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Hospitalization rate
Time Frame: 6 months
|
Rate of all cause and potentially preventable hospitalization as determined by encounters recorded in health information exchange data and categorized using AHRQ's prevention quality indicator definitions
|
6 months
|
Collaborators and Investigators
Sponsor
Sponsor
Collaborators
Collaborators
Investigators
Investigators
- Principal Investigator: Joshua R Vest, PhD, Associte Professor
Publications and helpful links
General Publications
- Kasthurirathne SN, Vest JR, Menachemi N, Halverson PK, Grannis SJ. Assessing the capacity of social determinants of health data to augment predictive models identifying patients in need of wraparound social services. J Am Med Inform Assoc. 2018 Jan 1;25(1):47-53. doi: 10.1093/jamia/ocx130.
- Vest JR, Grannis SJ, Haut DP, Halverson PK, Menachemi N. Using structured and unstructured data to identify patients' need for services that address the social determinants of health. Int J Med Inform. 2017 Nov;107:101-106. doi: 10.1016/j.ijmedinf.2017.09.008. Epub 2017 Sep 20.
- Vest JR, Menachemi N, Grannis SJ, Ferrell JL, Kasthurirathne SN, Zhang Y, Tong Y, Halverson PK. Impact of Risk Stratification on Referrals and Uptake of Wraparound Services That Address Social Determinants: A Stepped Wedged Trial. Am J Prev Med. 2019 Apr;56(4):e125-e133. doi: 10.1016/j.amepre.2018.11.009. Epub 2019 Feb 14.
Study record dates
Study Major Dates
Study Start (Actual)
Study Start
Primary Completion (Actual)
Primary Completion
Study Completion (Actual)
Study Completion
Study Registration Dates
First Submitted
First Submitted
First Submitted That Met QC Criteria
First Submitted That Met QC Criteria
First Posted (Actual)
First Posted
Study Record Updates
Last Update Posted (Actual)
Last Update Posted
Last Update Submitted That Met QC Criteria
Last Update Submitted That Met QC Criteria
Last Verified
Last Verified
More Information
Terms related to this study
Keywords
Other Study ID Numbers
Other Study ID Numbers
- VEST-RWJF-PHASE2
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Health Social Determinant
-
NCT04587869TerminatedHealth Care Utilization | Discrimination, Social
-
NCT02959866CompletedSocial Determinants of Health | Social Isolation | Poverty | Social Marginalization
-
NCT07465770Enrolling by invitationSocial Isolation | Health Services Accessibility
-
NCT03945994CompletedMental Health Wellness 1 | Social Isolation | Social Interaction
-
NCT04151056UnknownPrimary Health Care | Social Determinants of Health
-
NCT07218965RecruitingLoneliness | Social Isolation | Rural Health
-
NCT03949725CompletedMental Health | Loneliness | Health-Related Behavior | Social Isolation
-
NCT04514133CompletedHealth Attitude | Mental Health Wellness 1 | Social Interaction
-
NCT02746393CompletedConditions Influencing Health Status | Social Determinants of Health
-
NCT07550101CompletedPrimary Health Care | Healthcare Disparities | Social Determinants of Health | Health Equity
Clinical Trials on Risk screening tool exposure
-
NCT02455505Active, not recruiting
-
NCT05251311CompletedSocial Determinants of Health | Low-income Populations
-
NCT03705897Active, not recruiting
-
NCT02959866CompletedSocial Determinants of Health | Social Isolation | Poverty | Social Marginalization
-
NCT05535140Completed
-
NCT04862728Not yet recruitingNutrition Disorder, Child