Senxi Du B.A., University of Southern California, Keck School of Medicine, Los Angeles, California
Kira Watson M.D., M.P.H., Division of General Internal Medicine and Division of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
Andrew Young D.O., Division of Geriatric, Hospital, Palliative and General Internal Medicine, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, california
Food insecurity has been shown to be associated with chronic diseases, increased healthcare use, and higher healthcare costs. While the majority of literature addresses the outpatient and community settings, there is little known about food insecurity in the inpatient setting. Survey data was collected to determine the prevalence and characteristics of food insecurity among hospitalized patients at an urban county hospital. A pilot survey (n=150) and secondary survey (n=76) were conducted several months apart and revealed a consistent prevalence of food insecurity of 37% and 39% respectively. Of the 26 patients who were enrolled in CalFresh, 65% continued to report food insecurity. There is a high prevalence of food insecurity in these samples of inpatients at an urban, county hospital. There is a need for formalized screening and intervention in the inpatient setting, as this could reach many patients who do not receive regular outpatient or other medical care. Key Words: food insecurity, health disparities, inpatient setting, hospital medicine Abbreviations: LAC+USC: Los Angeles County + University of Southern California
There are well-established associations between food insecurity and poor physical and mental health outcomes, increased healthcare use, and higher healthcare costs.1-3 Medical organizations, such as the American Academy of Pediatrics and the Annals of Internal Medicine, have advocated for healthcare systems to take an increased role in addressing food insecurity.4, 5 Existing research focuses on outpatient and community settings, and there is limited data about food insecurity in the inpatient setting. To our knowledge, only one study has investigated food insecurity prevalence among recently discharged inpatients.6 In 2019, a nationwide survey of over 700 hospitals found that only 40% of the hospitals were screening for food insecurity, with lower screening rates at non-academic medical centers compared to academic teaching institions.7
With proper screening and resource distribution, all medical centers have the potential to assist a greater number of patients in need of food resources. Addressing food insecurity in the inpatient setting is pivotal for successful discharge plans that promote care for the whole person, particularly for vulnerable patients who may not otherwise interface with an outpatient healthcare system. This study aims to characterize food insecurity among hospitalized inpatients at an urban county hospital.
Retrospective data were obtained from a quality improvement initiative on food insecurity conducted in February 2019 at the Los Angeles County + University of Southern California (LAC+USC) Medical Center, an urban county hospital in Los Angeles, CA. LAC+USC provides care to a diverse, underserved population. In 2019, this center had over 30,000 inpatient admissions. Approximately 66% of admissions were for patients of Hispanic or Latino ethnicity, 73% for patients with Medicaid, and 11% for homeless patients.8
Patients included in this initiative were adults age 18 and older, admitted to the general medicine service, spoke English or Spanish as a primary language, and were able to respond to intake questions. Patients with missing data were excluded. This study incorporated verbal administration of the Hunger Vital Signs screening tool into routine intake.9 The results of the first survey prompted a second data collection period in September 2019, which sought to characterize food insecurity in the inpatient setting. The second set of questions explored age, CalFresh enrollment, access to nutritious foods, medication purchasing decisions, and housing stability in the same targeted population as the first dataset. Patients who screened positive were referred to food resources, including CalFresh enrollment assistance and an on-site community resource center.
Counts and percentages were used to describe food insecurity prevalence and characteristics, and analysis was conducted using Microsoft Excel v16.40 (Microsoft Corporation, Redmond, WA). This study was deemed exempt human subjects research by the USC Institutional Review Board. Results
The prevalence of food insecurity was 37% among the 150 eligible patients from the first survey. The second survey of 76 patients corroborated this finding with a similar prevalence of food insecurity of 39%. In the second sample, the average age of food insecure patients was 49 years old (range: 20-82 years) and of food secure patients was 45 years old (range: 22-90 years). Of the 26 patients enrolled in CalFresh, 65% reported persistent food insecurity. Compared with 83% of food secure patients, only 34% of food insecure patients reported access to nutritious foods (Figure 1). Similarly, 38% of food insecure patients reported foregoing purchases of medication in order to purchase food, whereas no food secure patients reported such experiences. All seven patients who reported unstable housing also reported food insecurity.
Figure 1. Counts and percentages of food secure and food insecure patients who reported "yes" to each category
This study demonstrated an extremely high prevalence of food insecurity among inpatients admitted to an urban county hospital. The prevalence was consistent between the two samples obtained several months apart. To our knowledge, there is only one published investigation of inpatient food insecurity, which found a prevalence similar to that in our study.6 Our results also suggest CalFresh enrollment is generally insufficient as a singular intervention for reducing food insecurity as the majority of CalFresh enrollees in our sample still reported food insecurity. Additionally, food insecurity was not limited to patients with unstable housing. These findings regarding CalFresh enrollment and housing status are consistent with the literature.2, 6, 10 The heterogenous nature of food insecurity among hospitalized patients calls for multi-faceted initiatives to increase patient access to nutritious, affordable food following discharge.
Formalized universal screening for food insecurity in the inpatient setting may benefit a large number of patients at our medical center. This setting is unique in that many admitted patients are not empaneled with our outpatient clinics, where screening for the social determinants of health has become routine. Food insecurity screening should be performed for hospitalized patients in order to counteract selection bias against marginalized populations who may not receive regular outpatient care. Future initiatives may include systematic investigation of the benefits of universal screening by recording the number of screened and referred patients, along with quantitative survey-based assessment of individual patient care experiences.
The findings highlight opportunities to support patients who screen positive for food insecurity in the inpatient setting, including improving referrals to and uptake of existing food resources, increasing CalFresh enrollment, and coordinating with local food banks.11 For example, the Wellness Center associated with the LAC+USC Medical Center is a critical preventive health venue for vulnerable patient populations; it is conveniently located on the medical campus and serves to connect patients with community resources, education, and produce distribution.12
This study has several limitations, including those inherent to small convenience samples. Even though our samples were obtained at different points in the year, the surveys were administered over a brief time-period, and thus, the results may not accurately reflect shifting hospital demographics over the course of an entire year. Given the sensitivity of this subject, survey results may also underestimate the true prevalence of food insecurity in the population. Additionally, this sample from a large urban county hospital may not be generalizable to other inpatient settings, such those that primarily serve rural environments. Future research is needed to characterize inpatient food insecurity and resource needs in other settings. Lastly, with rising food insecurity nationwide due to the 2019 novel coronavirus disease pandemic, the true prevalence at this time is likely higher than that observed in our study.
Inpatient hospital admission is a significant, but under-utilized opportunity for food insecurity screening. This study reveals a high prevalence of food insecurity despite the existing resources for intervention. There is opportunity for multi-faceted solutions to address the heterogeneous nature of food insecurity in healthcare systems. We hope this study promotes development of food insecurity screening capabilities and support for existing food insecurity interventions in the inpatient setting, in addition to encouraging institutions without such programs to develop resources.
Author, Article and Disclosure Information
Conflict of Interest: Authors report no financial relationships or interests to disclose.
Authorship: Authors are entirely responsible for the content of this manuscript.
Requests for reprint should be addressed to Southern California Journal of Medicine at email@example.com
We would like to acknowledge the Department of Utilization Review, their care coordinator team, and Department of Social Work at LAC+USC for their contributions.
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12. The Wellness Center at Historic General Hospital. Neighborhood Legal Services of Los Angeles County. https://www.nlsla.org/projects/the-wellness-center-at-historic-general-hospital/