In last week’s posting, I pointed out that people come to the ER, or for health care in general, for all kinds of reasons, not always obvious at first glance. In fact, it may be difficult to discern unless one asks very specific questions. And those needs may appear not to be “medical” at all.
But non-medical factors are a more important determinant of health than the care we provide. The best estimates are that medical care accounts for no more than 10% of an individual’s health status, while behavior accounts for 40% and social/environmental factors, 20% (the remaining 30% belong to genetic predispositions). One could argue that we’d get far better results focusing on behavior and environment than on medications.
As is so often the case, the Canadians are far ahead of us on this. A Toronto family physician is pushing for incorporating poverty screening into routine health care, an approach being promoted by the Ontario Medical Association as well. Dr. Bloch points out that poverty is the second leading cause of lost life in Canada after cancer. (I wonder how the US would compare?) He has developed a screening question – “Do you ever have difficulty making ends meet at the end of the month?” – that has 98% sensitivity and 64% specificity for predicting economic need. (That performs better than a CBC in predicting infection, something we do all the time at $71.50 a pop.)
Identifying people under economic stress has several benefits. First, unrecognized poverty may mean that people will be unable to obtain prescribed medications or have recommended follow up. It may also cause or exacerbate a variety of conditions. One example: a new study in Health Affairs showed that lack of money for food at the end of the month leads to increases in admissions for hypoglycemia in people with diabetes. Moreover, in early childhood, chronic stress such as that associated with poverty has a long-lasting, and in many cases heritable, biological impact via changes in the developing brain and epigenome. Early recognition and intervention may be helpful, and is an area of focus for the American Academy of Pediatrics.
Children’s Hospital of Wisconsin has a vision that the children of Wisconsin will be the healthiest in the nation. The care we provide will only accomplish 10% of that. We must therefore pay attention to all of the factors that affect the health of the kids we serve. Identifying economic needs and working to end poverty will accomplish even more.