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Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs
  1. Colleen Gillespie1,2,
  2. Jeffrey A Wilhite1,
  3. Kathleen Hanley1,3,
  4. Khemraj Hardowar1,
  5. Lisa Altshuler1,
  6. Harriet Fisher1,
  7. Barbara Porter1,
  8. Andrew Wallach1,3,
  9. Sondra Zabar1,3
  1. 1 Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
  2. 2 Institute for Innovations in Medical Education, NYU Grossman School of Medicine, New York, New York, USA
  3. 3 Ambulatory Care, New York City Health + Hospitals, New York, New York, USA
  1. Correspondence to Jeffrey A Wilhite, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; Jeffrey.Wilhite{at}


Background Although efforts are underway to address social determinants of health (SDOH), little is known about physicians’ SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs.

Methods Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a ‘proxy’ comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams.

Results 108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%–60%; p=0.045) and declined for the proxy comparison (61%–42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%–41%; p=0.004) but not for the comparison team (21%–29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams.

Conclusions Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.

  • Patient safety
  • Medical education
  • Healthcare quality improvement
  • Graduate medical education
  • Primary care

Data availability statement

No data are available. Data were collected and maintained as part of a research grant and are not available for sharing.

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Data availability statement

No data are available. Data were collected and maintained as part of a research grant and are not available for sharing.

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  • Contributors All authors have contributed substantially to this work and to the development of this manuscript. CG serves as guarantor.

  • Funding This work was supported by the Agency for Healthcare Research and Quality (AHRQ 1R18HS024669-01) and the Health Resources & Services Administration (HRSA 15-A0-00-004497).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.