LABUN:
Welcome to the fifth episode in our series of short explainers for the Hunger Vital Sign tool. We’ve already introduced the tool, explained how we know it’s valid, and also reliable, and now we’ll get to the question of whether it’s useful. I’m your host, Helen Labun. And to help with the explanations, we have a guest expert from the organization that created the Hunger Vital Sign.
SHEWARD:
I'm Richard Sheward, Director of Innovative Partnerships at Children's HealthWatch
LABUN:
To define the utility of Hunger Vital Sign, let’s begin with the original goals.
SHEWARD:
The goal of creating the Hunger Vital Sign was to develop a brief screen that would identify families who are at risk of food insecurity. And the reason for doing this was that medical providers, the health care team, needs an efficient method for identifying individuals and food insecure households to then ensure that these families have access to nutrition related services that will provide healthy food and alleviate food insecurity, care for stress, and all the outcomes related to food insecurity.
LABUN:
The previous episodes went over how researchers developed a screen within defined boundaries for accuracy in identifying families at risk of food insecurity, and connecting that result to the likelihood of poor health outcomes. We also went over how the original tool, tested for young children, expanded to include all age groups.
But we’ve also talked about one of the key challenges in saying whether or not the Hunger Vital Sign is useful – a screen is only a first step. You can’t measure ‘useful’ in the abstract. It’s a bit like needing to get to your friend’s house a few towns over, you’ve got a car in the driveway with a 93% chance of starting up once you turn the key – is that car useful? Well, you don’t really know until you drive it. Even if it will start up, if you never use it then it’s still an unuseful barrier, sitting there blocking your driveway.
One way to gauge whether the Hunger Vital Sign is useful is to look at where it’s been adopted.
SHEWARD:
Since the Hunger Vital Sign was developed in 2010, there's been a large increase in its use adoption in a variety of settings, a variety of populations. Initially it was endorsed by the American Academy of Pediatrics. It's been endorsed by other professional associations over the years. In 2017, the Centers for Medicare and Medicaid services incorporated the Hunger Vital Sign into their accountable health community screening tool. And most recently we've seen the National Quality Forum measure incubator develop three food insecurity quality measures, as well as the American Board of Pediatrics, which developed a food insecurity quality improvement module. Both of those utilize the Vital Sign. So it's been used not just by individual clinicians and institutions, but it's being used in population health initiatives led by CMS, it's being used in national quality improvement initiatives both at the pediatric specialty level and in general medical practice.
LABUN:
So, a lot of use. And in the last episode we also discussed how the research community continues to test the Hunger Vital Sign in new applications, for example across communities with different food cultures or in combination with other screening tools to assess a broader range of health-related social needs.
As the Hunger Vital Sign tool leaves the research world and goes into common practice, that’s also where we can see how the details behind its development matter. Remember last episode when we discussed what happens if you convert the answer options into a yes / no statement.
SHEWARD:
So what they did was they replaced the three part response options to both the HFSS and the hunger vital sign with simplified yes or no options. And what they found was that the yes or no response option resulted in missing nearly a quarter of food insecure adults.
LABUN:
If you’ve connected this screening tool to being flagged as potentially eligible for benefits like food assistance from the health care system, then getting skipped due to a wording change has real consequences, cutting families off from support that could make a difference to their health and wellbeing.
Getting the sensitivity and specificity right also matters as a practice reviews the results of this screening across all their patients, as a way to decide on strategic priorities or community programs.
SHEWARD:
I think one of the most important aspects of being able to document food insecurity in the electronic health record is to have evidence to then point to, to understand that this is an actual problem for many people and that it's part of their care plan. It's not something that is assumed or unassumed; known or not known. It's something that is documented. And it also builds up to then policy decisions that are made, whether or not certain investments are made, based on the prevalence of food insecurity. So hospitals that want to address issues around equity, if they have the data, they can use that information in their response to the realization that food insecurity is truly an issue for their patient population.
LABUN:
Sensitivity, how well a tool identifies people with the condition, is clearly needed to document that this issue exists in a community. But specificity, how well a tool identifies people without the condition, is critical too – otherwise a health care system may overestimate the costs of some interventions and choose to forgo, or scale back, what would have been the best solution. Anecdotally, we hear of this problem in Medically Tailored Meals, a highly targeted and relatively complicated food-based intervention, where mis-understanding the number of patients who will participate can make health systems balk at paying for the program over a cheaper alternative.
And what about our statistical friend ‘convergent validity’? Remember that’s where the original researchers connected the food insecurity screen to a cluster of different indicators that they knew suggested health risks for young children. That research offered a starting point. For addressing all health-related needs connected to food security, a health care practice would have to think through the workflow that directs patients to the correct next steps.
SHEWARD:
The Hunger Vital Sign, when used as a screener, is really the first step in what could result in a more detaileed assessment. You want to be able to truly not just screen for, but then diagnose, what is the level of food insecurity? What is the depth of food insecurity? And then, in the context of a registered dietician, provide a diet-based health intervention. That's when a follow up nutritional assessment would also take place.
LABUN:
Registered dietitians are one example. Maybe the patient being screened is in the hospital and will work with a care transition team to prepare to return home, maybe they’re working with their primary care provider on risk of heart disease and will focus on certain diet changes plus a prescription for cholesterol-lowering medication. Or the next step is outside of the health care practice, with a community organization focused on non-medical needs – maybe to solve transportation gaps or connect a patient who has trouble cooking with a meals program.
The flip side of this need for a next step is that health care providers may feel uncomfortable knowing when they have enough options to serve the potential needs a food insecurity screen will uncover.
SHEWARD:
I think there are real concerns that clinicians face in identifying a need, working with a patient to try to address that need. And there's the risk of not being able to address that need and then you know, losing trust and, and degrading the relationship between the patient and the provider. But that being said, there are a number of response options that are available.
LABUN:
The options will never be perfect. Part of asking the food insecurity questions in a structured away, across all patients, is to show a health care practice where gaps exist so that programs can evolve. And we shouldn’t downplay current options. Knowing food insecurity status is a part of care planning and we have federal nutrition programs to ensure there are always some first steps available, even as the range of community-level responses evolve to meet all the needs identified through screening and the conversations that follow.
SHEWARD:
I think this is an area where screening for food insecurity really is, you know, years ahead of other health related social needs that are screened for, and hopefully addressed in some meaningful way. What I mean is that there is a robust menu of options that clinicians in institutions of all sizes can take. There's research that shows that really well-curated and crafted information on resources available to patients outside of the four walls of the hospital or clinic is effective. It has to be well curated and well framed. And, you know, in concordance with the patient's goals and interests and shared decision making, versus here's a phone number to a food bank that may or not be accessible to you, or at the hours that you're available.
There are the federal nutrition programs like SNAP and WIC. Anyone that's eligible can receive this intervention. And it behooves healthcare agencies to really deeply develop partnerships with the community-based organizations in their area and in the areas that their patients live and work.
One thing that Hunger Vital Sign is not meant to be is data gathering for its own sake - intentional research project, that’s fine, collecting data for no clear reason, that’s not. And this is one question that some groups have raised about potential requirements for social risk screening in health care - does making screening into a checkbox on a regulatory sheet turn it into an exercise in compliance and not a first step in assisting patients? Perhaps we’ll do some follow up episodes as that debate plays out.
Here’s a recap of where we stand now:
- Understanding whether Hunger Vital Sign is useful depends on determining what it’s meant to be used for. It’s rarely useful on its own. The original intent for a screen is as a first step leading to different potential pathways for follow up.
- We can get a sense of whether medical practices find it useful by observing how it has become a recommended clinical tool over the years since its introduction.
- We can also get a sense of its utility by looking at use cases for how it might be implemented. For example, if you are connecting a screening to potential benefits eligibility, then the validation elements we looked at in previous episodes become important and make Hunger Vital Sign more useful than non-validated tools. Those use cases also show the way the flexibility of Hunger Vital Sign is useful. For example, a practice may use the screen as part of referring patients to assistance with basic food access within the community or to clinical follow up with someone like a registered dietitian or both. It’s a valid first step either way.
- Finally, we can ask whether – in general – we would expect a next step to be available to a given health care practice. Because food is a component of care plans for common health conditions and because we have a federal system of food security programs, we can predict that a next step exists. We also know that in most places those options are far from perfect, and gathering more information can help build plans to create better options in the future.
Go on to the next episode where we tackle the question of what happens to a risk screening tool like Hunger Vital Sign as its use expands to more locations and it becomes a standard part of health care practice operations. Don’t forget to check the link in the show notes for more resources and information, including toolkits on Hunger Vital Sign implementation.