Addressing health gaps in Singapore: Harnessing data to build effective interventions

The concept of health inequities gained attention in the 1980s, with the phrase “social determinants of health” (SDoH) coined shortly thereafter. 1 Decades later, SDoH are recognized as key drivers of health inequities that—taken together—cost the United States (US) 421 billion in 2018. 1 Health inequities are not a uniquely US phenomena; more attention from policymakers in all countries is urgently needed to efficiently allocate resources and address root causes. In this issue of the Journal of Hospital Medicine, Goh et al. report from Singapore on the development and implementation of a social risk screening tool for hospitalized patients. 2 Among 320 patients (median age 75) admitted to four general medicine units, 33% were classified as higher social risk, defined as having more than two risk factors including: education, employment, social support, finances, housing, transportation, or language. Higher social risk was associated with a 48% longer length of stay (LOS) and 3545 in added costs per admission. Based on these results, the authors conclude that, in 2022, hospitalized patients with higher social risk cost their hospital an additional 25 million. While Singapore differs from the US in many ways, the findings from this study echo those seen in US studies: greater social needs are associated with increased medical costs. In the US, solution-oriented approaches to address health inequities have been difficult to implement given inequities are often deeply embedded in long-standing structural factors; altering these factors requires coordinated and persistent efforts to research and subsequently test and scale successful interventions. US medical organizations recommend that systematic screening for social needs in health care be integrated into clinical workflows, that interprofessional teams be established to help patients navigate available resources, and that increased research efforts evaluate the health impact and effectiveness of potential interventions. 3 The inpatient setting, specifically, is often cited as a potential touch point to identify patients with unmet needs, making hospitalists key players in proposed interventions. In this study by Goh et al. , physicians were responsible for completing the social risk screening tool. However, the authors admit that this added burden is not sustainable. Fortunately, because of its unique national and health system characteristics, Singapore could instead leverage publicly available data, including information on income, government-assisted housing, and unemployment benefits, to systematically screen patients as part of its SDoH measurement efforts. Given its public health insurance and public infrastructure, such as subsidized housing, strong school systems, and a progressive tax system, Singapore may also be uniquely positioned to make progress into addressing health inequities. 4 Additionally, most Singaporeans express a willingness to have their de-identified personal data used for medical research by their government and universities, even in the absence of consent for every study. 5 Goh et al. 's efforts represent a commendable start to understanding patients with higher social needs. Future research in this field—not just in Singapore—should focus on larger evaluations of processes and outcomes to (1) identify SDoH and structural drivers across multiple conditions that can inform broader national health policies and to (2) measure effectiveness of new precision health delivery approaches. As an example, patient outcomes—such as readmission rates, timely outpatient follow-up, and in-hospital or short-term mortality—may provide more useful effectiveness data than Goh et al. 's selection of LOS in terms of measuring the impact of SDoH on health care costs and utilization. These patient-level outcomes may provide a more accurate reflection regarding how SDoH affect health itself, rather than health care. Goh et al. 's study illustrates that health is distributed unequally. Singapore has the potential to make large inroads in evaluating and addressing health inequities by capitalizing on well-connected social safety net and healthcare systems. Healthcare stakeholders interested in effective interventions to address SDoH should follow the Singaporean story for successes and failures, which are inevitable in this complex space. Dr. Farah A. Kaiksow's work is supported by the National Institutes of Health (NIH) under award number 1K23AG083113. The authors declare no conflicts of interest.