The health of urologic patients is shaped by many factors. Access to affordable, high-quality health care is essential, but most health is not determined by clinical medicine.¹ When unfulfilled, education, economic stability, health behavior, community context, housing, and neighborhood environment all represent potential hazards that can influence health outcomes. These nonmedical factors are denoted as social determinants of health (SDOH; Figure). Within the US, the populations that are most affected by SDOH are racial and ethnic minorities, immigrant populations, the impoverished, and rural inhabitants. Within each of these populations, social determinants can limit access to high-achieving health care facilities and specialty care.² As urologists, it is critically important for us to understand the impact of SDOH on access to care and the downstream implications for patients with benign and malignant genitourinary (GU) conditions.

Figure. Social determinants of health. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved February 19, 2024, from https://health.gov/healthypeople/objectives-and-data/social-determinants-health.⁸

Vulnerable Populations in Urology

Within urology, SDOH are known to have disproportionate impact on vulnerable populations. Patients with GU malignancies, who also suffer from SDOH, are susceptible to delayed diagnosis resulting in advanced stage at presentation, restricted access to high-volume comprehensive cancer centers resulting in narrowed treatment options, and limited ability to seek second opinions: all potentially compromising their overall survival.^3,4 In a Pennsylvania Cancer Registry study of 3362 patients with nonmetastatic muscle-invasive bladder cancer, Miller et al identified markers of SDOH (Medicaid insurance status and Area Deprivation Indices 3 and 4) as independent predictors of overall mortality (P < .05).⁵ Female sex and Medicare insurance status were also associated with worse overall and bladder cancer–specific mortality (P < .05) in this cohort. Likewise, in a study by Sekar et al, patients residing in the highest Social Vulnerability Index counties were disproportionately racial and ethnic minorities, and more likely to undergo open radical cystectomy for muscle-invasive bladder cancer without receiving neoadjuvant chemotherapy (P < .05), a historic standard of care known to increase overall survival by 5%.⁶ Those least likely to receive neoadjuvant therapy before surgery were in the highest Social Vulnerability Index quintile with their breach in care driven by socioeconomic status, average household income, and disability.

Insurance status can also negatively impact the cancer outcomes of patients with advanced renal cell carcinoma. In a study of more than 18,000 kidney cancer patients presenting from 2007 to 2009, uninsured or Medicaid-enrolled patients were more likely to present with advanced disease but less likely to receive treatment (P < .001) compared with privately insured patients.³ These individuals suffered greater disease-specific mortality, perhaps as a consequence of greater stage at initial presentation and less intense cancer-directed therapy (P < .001). Likewise, Medicaid-enrolled patients experience less prostate cancer screening, are 4 times more likely to present with metastatic disease, and twice as likely to die from prostate cancer compared to those with private insurance.⁷

Social determinants can also result in a disproportionate incidence of benign GU conditions, such as voiding dysfunction. Okada et al found that study participants reporting food insecurity (commonly associated with a diet composed of majority bladder irritants) had a 55% greater risk of urge urinary incontinence compared to those without food insecurity (P < .001).⁸ Likewise, others have reported associations between overactive bladder symptom severity and food insecurity, financial strain, unstable employment, and difficulty concentrating.⁹

Pediatric patients represent another vulnerable population given their dependency on others to address medical conditions. Social determinants can negatively impact their time to diagnosis and definitive treatment, potentially resulting in lifelong deficits. Pittman et al demonstrated this predicament in a cohort of children with symptoms of testicular torsion.¹⁰ Boys with public insurance were found to have significantly longer time intervals from reported symptom onset to presentation (P = .004) and had an increased risk of orchiectomy.

Reducing the Impact of SDOH on Health Care Access

As clinicians, we are responsible for understanding the contexts of our patients’ lives in order to recommend the most appropriate disease management. As we identify patients negatively impacted by SDOH, we must leverage our access to interdisciplinary partners to mitigate barriers to care. These partners include social workers, case managers, discharge planners, health equity officers, and patient navigators who can identify key needs of at-risk patients with deficits in insurance coverage, lower socioeconomic status, deprived communities, and housing or food insecurity. Many health systems have integrated tools into the electronic health record to document SDOH circumstances and accelerate social supports. Patient navigation programs are particularly helpful for patients interacting with the health care system for complex disease management. This critical assistance may be more accessible in 2024 as the Centers for Medicare & Medicaid Services recently announced changes in Medicare payments and reimbursements that will now permit coverage for patient navigation.¹¹ Clinicians may also document their experience and expanded care for the vulnerable patient through secondary SDOH Z55-Z65 billing codes, particularly Z59.82 (transportation insecurity), Z59.86 (financial insecurity), and Z59.87 (material hardship), which increase visit complexity and time.

Apart from insurance needs, patients impacted by SDOH are commonly limited in their health care access by a lack of reliable transportation. Early conversations regarding transportation arrangements with social support systems, public utilities (bus, taxi, or rideshare), or the provision of gas cards may permit easier navigation to and from screening, treatment, and surveillance appointments. Moreover, a conscious effort to reduce the burden of routine office visits should be undertaken, beginning with the local attainment of laboratory tests and imaging (if feasible) when patients have an extended or burdensome travel commute. Increased deployment of telehealth appointments could decrease travel and time constraints to and from facilities.² Local community clinics and health centers have provided free broadband access to facilitate virtual health care visits for those without adequate resources or smartphone capability.¹² Moreover, electronic medical record-based “visits” can facilitate the completion of patient surveys, patient-reported outcome queries, and other tools to advance personalized plans of care.¹³

Home health care is another strategy to address subacute medical needs while minimizing patient burden. Electronic systems and digital applications provide real-time measurements of vital signs, activity level, and other key physiologic parameters that can be monitored remotely. These now exist for voiding diary assessments as well.¹⁴ Home-based fecal immunochemical testing has increased colorectal cancer screening and diagnosis, while mobile breast and lung cancer screening initiatives in rural communities have streamlined care for patients and maximized exposure to critical health services.^15,16 Partnerships with platforms such as DispatchHealth also provide acute medical care in the home setting through advanced practice providers who treat illness or injury with remote support from an emergency medicine physician when needed.¹⁷

Conclusions

Social determinants affect our health care system, within and outside the field of urology, in every way. From economic stability to level of education, social community dynamics to reliable transportation, our most vulnerable patient populations are critically impacted. These barriers to care lead to delayed diagnoses, higher stage at presentation, and limitations in treatment options, which diminish patient and disease outcomes. Contemporary medical practice requires generalists and specialists to work together to treat the “whole patient.” We must be engaged in capturing social data from patients, expanding our treatment team, and embracing novel tools that will increase the convenience of our care without compromising quality. In this way, our patients can achieve the full range of urologic access that they need and deserve.