HSS Investigators Address the Impact of Social Determinants of Health and Perception of Discrimination on Health Outcomes in People with Rheumatologic Diseases

Investigators from Hospital for Special Surgery (HSS) presented provocative evidence showing how social determinants of health (SDOH) and perceived discrimination influence the care and outcomes of people with rheumatologic diseases, such as lupus, and demonstrated how healthcare providers can screen for SDOH during patient encounters. They made these presentations at ACR Convergence 2025, the annual meeting of the American College of Rheumatology, held in Chicago from October 24-29.

"Social determinants of health - such as food insecurity, low health literacy, limited language proficiency, and limited education - are responsible for more than 70 percent of adverse health outcomes and drive inequities in care," explained Jillian Rose-Smith, PhD, MPH, MSW, Vice President and Chief Equity Officer at HSS. "Rheumatologic conditions are unpredictable and unrelenting. If a patient's physician gave them an expensive biologic medication, for example, treatment will fail if the patient doesn't have a refrigerator to keep it in. That's why it's so important for practice guidelines to align with patients' lived experiences."

Study: Predictors of 30-Day Readmissions in Pregnant Patients with Systemic Lupus Erythematosus: The Impact of Social Determinants of Health

Prior research on pregnancy outcomes in people with lupus has focused primarily on clinical risk factors and racial disparities. HSS investigators led the largest national study to date examining how SDOH affect hospital readmissions in pregnant women with lupus, who face disproportionately higher maternal health risks. Using an AI model called the Explainable Boosting Machine, which is capable of differentiating the effects of interconnected social and medical factors, the researchers analyzed hospital data from 28 U.S. states (2011-2021) to explore the influence of SDOH on 30-day hospital readmission rates among patients with lupus.

Among more than 66,000 women with lupus who were admitted to the hospital for pregnancy, 2,469 were readmitted within 30 days of discharge. Women who lived in lower-income neighborhoods and those with public insurance (Medicaid or Medicare) were much more likely to be readmitted within 30 days than those with higher incomes or private insurance. While these SDOH have been associated with poorer health outcomes in people with other medical conditions, their impact is magnified in patients with lupus, especially during pregnancy.

Women with serious medical issues - such as pre-eclampsia, chronic kidney disease, hypertension, anemia, and vascular complications - were also more likely to be readmitted.

The investigators were surprised to learn that readmitted patients were younger than those who were not readmitted - the opposite of what usually happens during pregnancy, where older mothers tend to have more complications. "This finding suggests that younger women with lupus may have more aggressive disease or severe disability, even though they're at an age when pregnancy is usually safer," said Sandhya Kannayiram, MD, an HSS rheumatology fellow and the study's lead author.

"Social determinants are vital, independent indicators of health outcomes in pregnant women with lupus. Addressing these factors, along with medical risk factors, is crucial for improving outcomes in this vulnerable group," she continued. The study also demonstrates that AI-powered models can aid clinicians in identifying patients who need extra support after hospital discharge so they can implement proactive, equitable interventions - such as connecting patients with resources for housing, childcare, and transportation, scheduling follow-up appointments before hospital discharge, offering telehealth services, and engaging community health workers.

Study: Addressing Perceived Discrimination in Lupus Care: Enhancing Patient Empowerment and Health Equity Through Education and Support

Systemic lupus erythematosus disproportionately affects Black, Latino, and Asian populations. Perceived racial discrimination in health care is a major concern among people with lupus and results in lower trust in physicians, less treatment adherence, and worsened health outcomes. HSS investigators from Charla de Lupus (Lupus Chat)®, a peer support program established over 20 years ago, conducted a survey to identify patients' self-reported experiences with perceived discrimination and healthcare navigation.

The idea for the survey stemmed from the Hospital's Community Health Needs Assessment, which highlighted discrimination and biases in health care identified by people living with lupus. People with lupus were surveyed before (37 patients) and after (23 patients) six monthly virtual support group sessions that provided education about recognizing and intervening when discrimination occurs in healthcare settings.

After the educational sessions, there was a measurable decline in perceived discrimination. Fewer patients felt they were treated with less courtesy and less respect or received poorer service, and fewer patients said that doctors or nurses acted superior.

A small number reported increases in feeling unheard or judged as unintelligent. "These increases reflect a new awareness and ability to recognize instances of bias, giving participants the language and confidence to name experiences they might not have previously identified," explained Kimberly Cabrera, Senior Program Associate for Charla de Lupus and the study's lead author. "Patients who took part in the virtual meetings reported feeling more empowered to advocate for themselves and experienced greater openness in communication with their providers, increasing their sense of trust in the healthcare system."

The study researchers also shared consented audio recordings from participants' focus groups with rheumatologists at HSS and nearby hospitals. Many were grateful to hear the patients' feedback and expressed an intent to integrate interventions to mitigate perceived discrimination and implicit bias concepts into their practices. "The result was not only a decrease in perceived discrimination among patients, but a greater mutual understanding between patients and providers - a reminder that progress is possible when what is valuable to patients is at the center, and both are willing to listen and work together," concluded Ms. Cabrera.

Presentation: Implementing Social Determinants of Health Screening in Rheumatology

Dr. Rose-Smith and her colleague Melissa Flores, MPH, MSW, Assistant Director, Office of Health Equity, will deliver a presentation outlining strategies for healthcare providers to implement SDOH interventions in their rheumatology practices. This session aims to equip rheumatology providers with the knowledge and resources needed to enhance care delivery and patient outcomes for underserved populations and ultimately promote a more inclusive, equitable care environment.

The presentation is designed to improve SDOH screening not only by rheumatologists, but also allied healthcare professionals such as nurses, physical and occupational therapists, social workers, and public health administrators - anyone in the care continuum with whom patients might share SDOH information. "You can give them the best advice and have the best care plan, but it falls apart in the end if you don't link patients with the appropriate resources or address what's going on in the places where they live, work, and play 95 percent of the time," said Dr. Rose-Smith.

The U.S. Centers for Medicare & Medicaid Services (CMS) and Joint Commission have issued regulatory requirements and other guidelines mandating healthcare providers to collect SDOH data. Building on an SDOH session presented at the ACR meeting in 2023, participants in the 2025 session will learn how to incorporate SDOH assessments into clinical workflows, identify key barriers to care related to social factors, and leverage data to identify disparities and develop targeted interventions.

The session will explore an example of a successful SDOH implementation and intervention process at HSS. The Hospital automated its SDOH process and launched an onsite food pantry last March as a result of SDOH screening, in collaboration with Food Bank NYC. Rheumatology patients who are identified as being food insecure during SDOH screening will be directed to the food pantry to receive a bag of groceries, which is especially important for those who need to take their medicine with food. "By asking open-ended questions about SDOH, we invite patients to share this part of themselves with us so we can better provide high-quality care and meet their needs," said Ms. Flores.

SDOH is also a value driver because it improves patient retention, patient satisfaction, and clinical outcomes. Concluded Dr. Rose-Smith, "Participants in this session will learn how to integrate SDOH screening into patient encounters in a way that humanizes care while improving communication and building trust."

References

Predictors of 30-Day Readmissions in Pregnant Patients with Systemic Lupus Erythematosus: The Impact of Social Determinants of Health
Authors: Sandhya Kannayiram, Yiyuan Wu, Lisa Sammaritano, Michael Lockshin, Rich Caruana, Ware Branch, Jane Salmon, and Bella Mehta

Addressing Perceived Discrimination in Lupus Care: Enhancing Patient Empowerment and Health Equity Through Education and Support
Authors: Kimberly Cabrera, Priscilla Calvache, Lillian Mendez, Giselle Morales, and Jillian Rose-Smith

Implementing Social Determinants of Health Screening in Rheumatology
Presenters: Jillian Rose-Smith, Melissa Flores