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Measuring Agreement Between Nursing Bedside and Comprehensive Preoperative Screeners for Health-Related Social Needs Before Elective Major Surgery
Kurt S. Schultz
*, Samantha Linhares, Elizabeth L. Godfrey, Bailey Thomson Blake, Eliza J. Epstein, Yuqing Huang, Ira L. Leeds
Surgery, Yale School of Medicine, New Haven, CT
Background: In 2024, the Centers for Medicare and Medicaid Services (CMS) mandated that hospitals in the United States collect health-related social needs (HRSNs) from all admitted patients. This study evaluated the agreement between two HRSN screening tools administered to patients undergoing elective major surgery.
Study Design: This prospective study involved adult patients who underwent elective major surgery within a statewide healthcare system from June 1, 2023, to March 1, 2025. Bedside nursing staff screen all admitted patients for four core HRSN domains using the CMS Accountable Health Communities (AHC) tool: housing insecurity, transportation needs, food insecurity, and utility difficulties. These domains were also screened prospectively as part of a researcher-administered comprehensive preoperative telephone screener within two weeks before surgery. Each patient's overall HRSN risk score was calculated by assigning one point for each HRSN domain present (range: 0-4). Cohen’s kappa coefficients were utilized to measure the agreement between these two HRSN screeners.
Results: 481 patients met the inclusion criteria (median age: 65.0 years [interquartile range, 52.8-72.9]). 246 (51.1%) patients were assigned female at birth, 65 (13.5%) identified as non-white, 31 (6.4%) identified as Hispanic, 295 (61.3%) were married, 212 (44.1%) were employed, and 206 (42.9%) did not have private insurance as their primary insurance coverage. 126 (26.2%) were treated by the thoracic surgery service, 91 (18.9%) by the abdominal oncology service, and 264 (54.9%) by the colorectal surgery service. The most common indication for surgery was cancer (70.5%, n=339). On the bedside screener, 5
.2% (n=25) of patients reported one HRSN, 0.6% (n=3) reported two, 0.4% (n=2) reported three and 0% (n=0) reported four. In contrast, on the preoperative screener, 17.7% (n=85) of patients reported one HRSN, 4.8% (n=23) reported two, 2.9% (n=14) reported three, and 1.0% (n=5) reported four. The most prevalent HRSN domain captured by the bedside screener was utility difficulties (2.9%) compared to housing insecurity by the preoperative screener (18.5%). The overall HRSN risk score had poor agreement between the two screeners (?=0.128, p<0.001). For the four individual HRSN domains, Kappa analysis demonstrated poor-to-fair agreement between the two screeners (?=0.041-0.234; Table 1).
Conclusions: This study demonstrated a high discordance between a bedside nursing HRSN screener used in the inpatient setting and a preoperative, comprehensive HRSN screener conducted by research staff. These findings suggest that capturing social needs is context and operator dependent, with routine bedside screening of surgical patients missing 81% of their complete HRSN burden. Using routine care processes to identify HRSN domains jeopardizes meeting regulatory requirements and could result in inaccurate and ineffective HRSN mitigation.
Table 1. Prevalence of health-related social needs reported by patients undergoing elective major surgery based on two screeners and their agreement.
| Health-related social needs | Prevalence on Bedside Screenera | Prevalence on Preoperative Screenerb | Cohen’s Kappa (?) | p-value |
| Housing Insecurity | 1.3% | 18.5% | 0.041 | 0.023 |
| Transportation Needs | 1.3% | 6.0% | 0.154 | <0.001 |
| Food Insecurity | 2.3% | 7.3% | 0.234 | <0.001 |
| Utility Difficulties | 2.9% | 8.3% | 0.110 | 0.003 |
aBedside screener was administered by inpatient nursing staff.
bPreoperative screener was administered by a member of the research team.
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