Living in “Cold Spot” Communities Is Associated with Poor Health and Health Quality

Abstract

Purpose:Little is known about incorporating community data into clinical care. This study sought to understand the clinical associations of cold spots (census tracts with worse income, education, and composite deprivation).Methods: Across 12 practices, we assessed the relationship between cold spots and clinical outcomes (obesity, uncontrolled diabetes, pneumonia vaccination, cancer screening-colon, cervical, and prostate-and aspirin chemoprophylaxis) for 152,962 patients. We geocoded and linked addresses to census tracts and assessed, at the census tract level, the percentage earning less than 200% of the Federal Poverty Level, without high school diplomas, and the social deprivation index (SDI). We labeled those census tracts in the worst quartiles as cold spots and conducted bivariate and logistic regression.Results: There was a 10-fold difference in the proportion of patients in cold spots between the highest (29.1%) and lowest practices (2.6%). Except for aspirin, all outcomes were influenced by cold spots. Fifteen percent of low-education cold-spot patients had uncontrolled diabetes compared with 13% of noncold-spot patients (P < .05). In regression, those in poverty, low education, and SDI cold spots were less likely to receive colon cancer screening (odds ratio [

Comparison of Community-Level and Patient-Level Social Risk Data in a Network of Community Health Centers

“… 6 , 7 , 8 , 9 , 10 , 27 , 32 In this study, we assessed concordance between patient-reported social risks and community-level social deprivation among patients receiving care in a national network of CHCs. Building on previous work, 10 , 11 we defined cold spots as census tracts with SDI scores within the highest quartile nationally. Although there was some overlap between cold spot status and the presence of patient-level social risks, with 60.0% of those who reported at least 1 social need living in a cold spot census tract, 40.0% of patients who screened positive for at least 1 social risk did not live in a cold spot.…”

“… 18 Moreover, prior studies suggest that patients living in cold spots—defined as those census tracts with an SDI score in the highest quartile nationally (≥75)—have worse health outcomes relative to those in more resource-rich tracts. 11 …”

“… 14 Theoretically, such data could provide an alternative way to identify patients with social risks or to target patients for whom self-reported screening should be prioritized. 11 For example, community-level data could be used for “cold-spotting” to identify patients living in geographic areas that lack certain characteristics that support health, such as access to grocery stores and parks, higher rates of education and employment, clean air, and adequate housing. 15 Identifying patients who live in the most vulnerable communities, or “cold spots,” could help clinics characterize and understand patients’ social and economic contexts and/or target social risk screening efforts.…”

“…Specifically, we compared the social deprivation index (SDI) score for the census tract where a patient lives with patient-level social risk screening data documented in the EHR to assess whether patients who live in “cold spots” have more patient-level social risks. 11 , 15 …”

Advancing the Science of Implementation in Primary Health Care

“…[17][18][19][20] This critical challenge for primary care implementation scientists is addressed by several authors herein. Liaw et al 21 report on a novel approach to geocoded practice and population data to help primary care physicians identify and understand the effects of living in "cold spots"-areas with lower education, lower income, and greater composite scores of deprivation-on their patients. They used these methods to help 12 practices recognize that their patients living in cold spots had lower rates of receiving certain, but not all, preventive services and screening tests, a potential first step in targeting atrisk patients and developing mitigating interventions.…”