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Policy PointsThe health care sector is increasingly investing in social conditions, including availability of safe, reliable, and adequate transportation, that contribute to improving health.In this paper, we suggest ways to advance the impact of transportation interventions and highlight the limitations of how health services researchers and practitioners currently conceptualize and use transportation.Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy. [ABSTRACT FROM AUTHOR]

Policy PointsDissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low‐value health services.Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low‐value services.Multicomponent interventions targeting clinicians are currently the most effective types of interventions. Context: Choosing Wisely aims to reduce the use of unnecessary, low‐value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low‐value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. Methods: We searched peer‐reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi‐squared tests or Wald tests to compare across interventions. Findings: We reviewed 131 articles. Eighty‐eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician‐based interventions were more effective than consumer‐based, though there is a dearth of studies on consumer‐based interventions. Only 17% of studies included a control arm. Conclusions: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low‐value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high‐quality studies that include active controls. [ABSTRACT FROM AUTHOR]

Policy PointsHospitals address population health needs and patients' social determinants of health by offering social care services. Tax‐exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services.Tax‐exempt hospitals offer about 36% more social care services than for‐profit hospitals. Among tax‐exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services.Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients. Context: Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax‐exempt hospitals. Methods: National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state‐level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi‐square and t‐tests comparing for‐profit and tax‐exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax‐exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services. Findings: Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax‐exempt hospitals offered about 36% more social care services than for‐profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax‐exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient‐focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. Conclusions: Although tax‐exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation. [ABSTRACT FROM AUTHOR]

Policy PointsA large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming.We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH.In light of scarce existing SDOH mitigation strategies, the framework addresses an important research‐to‐practice translation gap and missed opportunity for advancing health equity. Context: The reduction of health inequities is a broad and interdisciplinary endeavor with implications for policy, research, and practice. Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms, and effective SDOH mitigation strategies remain scarce. To expand the cadre of effective SDOH mitigation strategies, a practical, heuristic framework for policymakers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDOH influence. Methods: We conduct a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms and to synthesize an integrated framework for conceptualizing such mechanisms. Findings: We highlight eight unifying principles of SDOH mechanisms that emerge from landmark SDOH research. Building on these principles, we introduce and apply a conceptual model that synthesizes key SDOH mechanisms into one organizing, heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing the key SDOH mechanisms that represent intervention opportunities to maximize potential impact for mitigating a given health inequity. Conclusions: Our synthesis of the extant SDOH research into a heuristic framework addresses a scarcity of peer‐reviewed organizing frameworks of SDOH mechanisms designed to inform practice. The framework represents a practical tool to facilitate the translation of scholarly SDOH work into evidence‐based and targeted policy and programming. Such tools designed to close the research‐to‐practice translation gap for effective SDOH mitigation are sorely needed, given that health inequities in the United States and in many other parts of the world have widened over the past two decades. [ABSTRACT FROM AUTHOR]

Policy PointsThe predominantly fee‐for‐service reimbursement architecture of the US health care system contributes to waste and excess spending.While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population‐based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity.To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value‐based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross‐sector entities to invest in the upstream drivers of health. [ABSTRACT FROM AUTHOR]

Policy PointsTo meaningfully impact population health and health equity, health care organizations must take a multipronged approach that ranges from education to advocacy, recognizing that more impactful efforts are often more complex or resource intensive.Given that population health is advanced in communities and not doctors' offices, health care organizations must use their advocacy voices in service of population health policy, not just health care policy.Foundational to all population health and health equity efforts are authentic community partnerships and a commitment to demonstrating health care organizations are worthy of their communities' trust. [ABSTRACT FROM AUTHOR]

Policy PointsLow‐value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low‐value care stems from the use of medical device‐based procedures.We describe here a novel academic‐policymaker collaboration in which evidence‐based clinical coverage for device‐based procedures is implemented through prior authorization‐based policies for Louisiana's Medicaid beneficiary population.This process involves eight steps: 1) identifying low‐value medical device‐based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low‐value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low‐value device‐based care. [ABSTRACT FROM AUTHOR]

Policy PointsPatients and families can identify clinically relevant errors, including "blindspots"—safety hazards that are difficult for clinicians or organizations to see.Health information transparency, including patient access to electronic visit notes, now federally mandated in the US and the subject of policy debate worldwide, creates a new opportunity to engage patients in diagnostic safety. However, not all patients access notes.Patient identification of blindspots in their notes underscores the need to systematically and equitably engage willing patients in safety, promote patient "good catches," and establish routine systems for patient feedback to help avoid preventable diagnostic errors and delays. Context: Policy shifts toward health information transparency provide a new opportunity for patients to contribute to diagnostic safety. We investigated whether sharing clinical notes with patients can support identification of "diagnostic safety blindspots"—potentially consequential breakdowns in the diagnostic process that may be difficult for clinical staff to observe. Method: We used mixed methods to analyze patient‐reported ambulatory documentation errors among 22,889 patients at three US health care centers who read ≥ 1 visit note(s). We identified blindspots by tailoring a previously established taxonomy. We used multiple regression analysis to identify factors associated with blindspot identification. Findings: 774 patients reported a total of 962 blindspots in 4 categories: (1) diagnostic misalignments (n = 421, 43.8%), including inaccurate symptoms or histories and failures or delay in diagnosis; (2) errors of omission (38.1%) including missed main concerns or next steps, and failure to listen to patients; (3) problems occurring outside visits (14.3%) such as tests, referrals, or appointment access; and (4) multiple low‐level problems (3.7%) cascading into diagnostic breakdowns. Many patients acted on the blindspots they identified, resulting in "good catches" that may prevent potential negative consequences. Older, female, sicker, unemployed or disabled patients, or those who work in health care were more likely to identify a blindspot. Individuals reporting less formal education; those self‐identifying as Black, Asian, other, or multiple races; and participants who deferred decision‐making to providers were less likely to report a blindspot. Conclusion: Patients who read notes have unique insight about potential errors in their medical records that could impact diagnostic reasoning but may not be known to clinicians—underscoring a critical role for patients in diagnostic safety and organizational learning. From a policy standpoint, organizations should encourage patient review of visit notes, build systems to track patient‐reported blindspots, and promote equity in note access and blindspot reporting. [ABSTRACT FROM AUTHOR]

Policy PointsPolicymakers at federal and state agencies, health systems, payers, and providers need rigorous evidence for strategies to improve health care delivery and population health. This is all the more urgent now, during the COVID‐19 pandemic and its aftermath, especially among low‐income communities and communities of color.Randomized controlled trials (RCTs) are known for their ability to produce credible causal impact estimates, which is why they are used to evaluate the safety and efficacy of drugs and, increasingly, to evaluate health care delivery and policy. But RCTs provide other benefits, allowing policymakers and researchers to: 1) design studies to answer the question they want to answer, 2) test theory and mechanisms to help enrich understanding beyond the results of a single study, 3) examine potentially subtle, indirect effects of a program or policy, and 4) collaborate closely to generate policy‐relevant findings.Illustrating each of these points with examples of recent RCTs in health care, we demonstrate how policymakers can utilize RCTs to solve pressing challenges. [ABSTRACT FROM AUTHOR]