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Publication Briefs

Subgroups of High-Risk VA Patients Based on Social Determinants May Help Predict Risk of Future Hospitalization

High-risk patients incur a disproportionate share of healthcare expenditures due to complex medical, social, and behavioral needs that lead to diverse outcomes and require diverse interventions. High-risk Veterans are difficult to efficiently treat on a population level due to their heterogeneity. Thus, it is important to identify clinically meaningful subgroups within the high-risk population in order to efficiently tailor or target interventions. There also may be meaningful subgroups of high-risk patients based on clusters of social determinants of health (SDH). The objective of this study was to identify discrete and clinically meaningful subgroups of high-risk Veterans that could help VA better tailor clinical and social services to the distinct needs of these populations. In partnership with VA’s Office of Primary Care, a survey was sent in 2018 to a nationally-representative random sample of 10,000 Veterans (4,684 Veterans responded) who had at least one VA outpatient visit between 3/20/2017 and 3/18/2018, and were considered “high risk” (defined as 1-year risk of hospitalization or death in the ≥75th percentile of VA’s Care Assessment Need (CAN) score). The final measures used to form sub-groups were three health status constructs: global health status (SF-1), functional status (Activities of Daily Living; ADLs), smoking status, and eight SDH constructs: loneliness, sleep quality, food insecurity, medication insecurity, depression, social support, patient activation, and recent life stressors.


  • Patients’ self-reported SDH measures can be used to identify meaningful subgroups that may benefit from tailored interventions to reduce their risk of hospitalization and other adverse events.
  • Five subgroups of high-risk Veterans with different risk for VA hospitalization emerged, those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized).
  • After adjusting for covariates, Veterans with ‘multiple SDH vulnerabilities’ were significantly more likely to be hospitalized at 6 months than those with ‘minimal SDH vulnerabilities.’


  • Efforts to screen and integrate information on multiple SDH measures into the electronic health record will facilitate identification of specific patients who are at increased risk of future hospitalization, and this could inform patient care and resource allocations.


  • This study included a fixed set of self-reported SDH measures; others may be more informative.

This study was funded by the Office of Primary Care, and Dr. Maciejewski was supported by an HSR&D Research Career Scientist Award. Dr. Blalock was supported by the Office of Academic Affiliations. Drs. Blalock and Maciejewski are part of HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC. Dr. Zulman is part of HSR&D’s Center for Innovation to Implementation (Ci2i) Palo Alto, CA.

Blalock DV, Maciejewski ML, Zulman DM, et al. Subgroups of High-Risk VA Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization. Medical Care. May 2021;59(5):410-417.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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