Social Isolation and Patient Experience in Older Adults

INTRODUCTION

Social isolation is defined as a state in which an individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts, and displays a deficiency in fulfilling quality relationships.¹ Social isolation has been identified as a major health problem, particularly in the elderly who lack good social networks that are a key element of social capital.² The negative effects of social isolation on health outcomes are supported by a wealth of evidence. According to previous studies, social isolation is associated with increased risk of all-cause mortality,^3,4 mortality from coronary heart disease/stroke,⁵ rehospitalization,⁶ falls,⁷ cognitive decline,⁸ and death from suicide.⁴ Moreover, socially isolated older individuals are at risk for negative behaviors, such as heavy drinking⁹ and poor nutritional habits.¹⁰

Social isolation may influence health outcomes and patient behaviors by having a negative impact on the patient experience. Patient experience is considered the most effective quality measure of patient-centeredness and is defined as providing care that is respectful of and responsive to patient preferences, needs, and values.¹¹ Patient experience is known to affect health outcomes through patient behaviors, such as adherence to treatment and health care resource use.^12,13 Previous studies have reported socioeconomic variation in patient experience,^14,15 and a few exploratory quantitative studies have suggested negative associations of social capital components with patient experience.^16,17 Additionally, a previous qualitative study identified social isolation as an unmet need in elderly primary care patients.¹⁸ Due to a lack of studies, however, an association between social isolation and patient experience of primary care remains unclear. It would be beneficial for primary care providers and policymakers to have a clear understanding of the relationship between social isolation and patient experience.

The aim of this study was to examine the association between social isolation and patient experience in elderly primary care patients.

METHODS

RESULTS

Of the 644 adult participants who responded to the survey, we excluded 162 participants aged <65 years and 17 participants who did not have a usual source of care. We carried out analyses of the remaining 465 eligible participants.

Table 1 shows the characteristics of the 465 eligible participants. The majority of the participants were females (54.4%), aged ≥70 years (71.8%), with less than college education (79.3%), and with multi-morbidity (74.8%). The proportion of socially isolated patients was 27.3%. The average JPCAT total score was 65.7 out of 100 points; the most highly scored domain was longitudinality with 81.2 points, and the most poorly scored domain was comprehensiveness (services provided) with 45.8 points. Table 1 also compares the characteristics of the socially isolated participants with participants who were not socially isolated. We noted a trend suggesting that the socially isolated participants had lower JPCAT scores and 5-item Mental Health Index scores.

Table 2 shows the results of the linear mixed effects model, examining the associations between social isolation and the JPCAT scores as measures of patient experience in primary care. Social isolation was negatively associated with the JPCAT total score, after adjustment for possible confounders and clustering within clinics (mean difference = −3.67; 95% CI, −7.00 to −0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores. Comprehensiveness (service provided) had the strongest association with social isolation (mean difference = −7.58; 95% CI, −14.28 to −0.88).

DISCUSSION

Our results revealed that social isolation was associated with a more negative patient experience of primary care, especially regarding longitudinality, comprehensiveness (services provided), and community orientation, among older Japanese patients who had a usual source of care. Based on previous results, a JPCAT total score difference of >3 points between socially isolated and not socially isolated patients in our study is considered sufficient in magnitude to have practical importance.

Our findings agree with previous exploratory study results about the associations between elements of social capital and patient experience.^16,17 Although having a social network is a crucial element of social capital, the association between social isolation and patient experience has been unclear. The results of our study contribute additional information about potential mechanisms by which social isolation influences health outcomes and patient behaviors. According to a previous qualitative study, service providers experience substantial levels of concern and frustration and have a sense of powerlessness about meeting the needs of socially isolated patients²⁹; however, there remains a lack of relevant data on what their care needs are. Our study identified longitudinality, comprehensiveness, and community orientation as unmet needs in socially isolated elderly patients in primary care. These findings might be helpful for primary care providers to address the needs of socially isolated patients; further studies are needed.

To the best of our knowledge, this is the first study to reveal the association between social isolation and the patient’s experience of primary care. Our findings were based on data from a nationwide multicenter primary care practice-based research network study covering both urban and rural areas and included a wide range of local health care delivery systems. Patient experiences differ by clinic; therefore, we adjusted clustering within clinics by using a mixed-effects model and allowed appropriate patient-level analysis.

Our study has several potential limitations. First, the participation rate was a concern. A previous study of patient experience surveys showed that a low participation rate did not introduce selective nonresponse bias,³⁰ however, it is possible that patients with lower quality patient experiences or social networks were less likely to respond to our survey. If so, this could cause an underestimation of the association between social isolation and patient experience in this study. Second, in the validation study of the JPCAT, although socioeconomic factors were employed to ensure that the selection of the sampling site represented the Japanese national standard, the sampling site was restricted to 1 urban area. Therefore, there were differences in the participants’ characteristics between the validation study of the JPCAT and this study that included rural practices. Construct validity of the JPCAT, however, has previously been verified in the population of this study.^31,32 Third, our survey setting was restricted to primary care clinics that had a known interest in health care quality. Although we covered a nationwide network of primary care clinics, caution should be exercised when generalizing the results of this study.

In conclusion, social isolation was associated with negative patient experiences in elderly primary care patients. Raising awareness about the importance of patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.