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Enhancing Patient-Centered Outcomes Research (PCOR): Creating a National Small-Area Social Determinants of Health Data Platform

Develop a Consolidated Set of National Standardized Databases on Valid and Reliable Social Determinants of Health Factors at the Small-Area Levels
  • Agency for Health Research and Quality (AHRQ)
Start Date
  • 3/1/2019
  • Standardized Collection of Standardized Clinical Data
  • Linking of Clinical and Other Data for Research


STATUS: Active Project


Given that a great deal of effort has been put toward improving the health care system processes and emphasizing prevention efforts in the population, policymakers are looking at other stressors on the health care system, including a better understanding of the community context in which health services are provided. In particular, there is a growing demand for a data platform that integrates information about social determinants of health (SDOH), health service utilization, and systems of care. For many decades, researchers have emphasized the importance of SDOH, and have developed many different conceptual models to explain the inter-relationship between individual, family and societal factors on the health of an individual. Research has demonstrated that for many SDOH factors, small-area data (data at the community or sub-county level) may be necessary to conduct meaningful analyses; and that for other SDOH factors, data at other geographic levels are more meaningful. Considerable evidence exists about the relationship between the inequities in SDOH factors and poor health outcomes (e.g., mortality, acute and chronic disease, disability). Some studies have shown a relationship between SDOH factors and health care utilization, and studies are just beginning to emerge on the effectiveness of the health care interventions that integrate patient and community SDOH information on patient and community health outcomes. Health care systems are already moving toward obtaining critical SDOH data to improve care coordination and the quality of health care services for vulnerable populations.

Researchers spend substantial resources linking multiple datasets to create data files suitable for analyses because, the current datasets lack standardized metrics or estimates at the small-area level. Those databases are often derived for the purposes of looking at the health of an individual or health of the community and include information about the neighborhood and built environment, health and health care, social and community context, education, economic stability. However, these databases are limited in their ability to examine the SDOH in the small geographic areas. There is no complete source of longitudinal information with uniformly-formatted community-level data on SDOH readily available for health service research.


The goal of the project is to develop a consolidated set of national standardized databases on valid and reliable SDOH factors at the small-area and other geographic levels, building on existing databases developed by federal agencies (e.g., Agency for Healthcare Research and Quality (AHRQ), Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), Assistant Secretary for Planning and Evaluation (ASPE), and National Institutes of Health (NIH)).

The overall objectives of the project are to:

  • Conduct an environmental scan to identify a comprehensive set of U.S. Department of Health and Human Services’ (HHS) and other federal datasets with existing or analyzable small-area level and other geographic level data on SDOH variables.

  • Design and create a publicly available data platform of valid and reliable standardized set of SDOH data sources at various geographic areas to include, but not limited to: census blocks, zip codes, counties, primary care service areas, market areas, and states.

  • Coordinate and expand the data collection efforts on SDOH across HHS.

  • Use the new data platform to conduct a minimum of two patient-centered outcomes research (PCOR) studies.

  • Disseminate the SDOH data platform to end-users across the federal government, PCOR researchers, and health services researchers.

  • Establish a sustainability and growth plan for the SDOH data platform.


The beta version of the AHRQ SDOH database is now available and includes county-level data from 2009 through 2018 and zip code-level data from 2011 through 2018 across five SDOH domains: social context; economic context; education; physical infrastructure; and healthcare context. The data can be used by external researchers to link to other datasets or look across counties and zip codes assessing SDOH-related characteristics.