Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Lauren E. Ferrante

Abstract

Health-Related Social Needs (HRSNs), such as financial strain, food insecurity, social isolation, and transportation disadvantage, are unmet social needs associated with poor health outcomes and increased healthcare utilization. In qualitative work, survivors of the intensive care unit (ICU) report financial strain; however, little is known about food insecurity, social isolation, and transportation disadvantage after critical illness. The objectives of this study were twofold: (1) to ascertain changes in three HRSNs—food insecurity, social isolation, and transportation disadvantage—from the year before critical illness to the year following discharge among older adult survivors of critical illness, and (2) to evaluate demographic, pre-admission, and in-hospital factors associated with each of the three HRSNs in the year after critical illness. We linked data from community-living participants in rounds 2–9 of the National Health and Aging Trends Study (NHATS) 2011 cohort to Medicare claims to identify ICU hospitalizations. The analytic sample included survivors who were not admitted from a nursing home, not discharged to hospice, and who had at least partially completed NHATS interviews before and after hospitalization. Food insecurity was assessed using a validated 5-item composite measure that draws from five discrete NHATS indicator variables and was codified as a dichotomous outcome for positive responses to ≥1 of the five indicator variables. Social isolation was determined using a validated 6-item composite measure that draws from six discrete NHATS indicator variables and was codified as a dichotomous outcome for positive responses to ≥ 3 of the six indicators, as previously described. Transportation disadvantage was assessed by drawing from four discrete NHATS indicator variables that evaluate the difficulty of participating in activities due to lack of transportation and was codified as a dichotomous outcome for positive responses to ≥1 of the four indicator variables. Factors associated with each HRSN in the year after critical illness were evaluated using population-weighted multivariable logistic regression. Of the 450 participants, the mean age was 80.1 (SD 7.1), 50.9% were women, and 110 (24.7%) were non-Hispanic Black individuals. Relative to the year preceding ICU admission, all three HRSNs increased in the year after critical illness. From the year preceding critical illness to that following discharge, the prevalence of food insecurity increased from 4.9% to 7.8%, social isolation increased from 31.9% to 39.4%, and transportation disadvantage increased from 10.5% to 15.6%. After adjustment, socioeconomic disadvantage (Medicaid eligibility) was associated with a greater odds of social isolation after critical illness (OR, 3.26; 95% CI, 1.38-7.70), as was pre-ICU social isolation (OR, 19.99; 95% CI, 10.29-38.84). After adjustment, mechanical ventilation in the ICU was associated with a greater odds of post-ICU transportation disadvantage (OR, 2.69; 95% CI, 1.03-7.01), as was pre-ICU transportation disadvantage (OR, 12.85; 95% CI, 5.60-29.48). No pre-ICU or in-ICU factors were significantly associated with higher likelihood of food insecurity. These findings emphasize the need for screening and interventions to address HRSNs among older survivors of critical illness.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 04/30/2025

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