Using factor analysis to streamline social screening for the emergency department

INTRODUCTION: Emergency departments (EDs) are increasingly required to screen for social risk and social need, but existing tools are long, hindering their utility in clinical settings, and resulting in incomplete surveys. However, strategies for streamlining screening tools remain unclear. This work aimed to guide future development of an ED-based screener by using a health system's ten-item social risk/social need questionnaire to (1) compare differences in patient populations by questionnaire completeness, (2) observe patterns of responses (e.g., what questions cover the same constructs and can potentially be eliminated), and (3) test for variation in social risk/social need measurement by age. 

METHODS: This cross-sectional study evaluated patients who responded to at least one question in the social risk/social need questionnaire in our regional health system from February 2019 to March 2023. Descriptive analyses examined patients stratified by questionnaire completeness: lower response (< 60%) versus higher response (≥ 60%). Within the higher response group, factor analysis extracted social risk/social need constructs and the strength of the association between each questionnaire item and its corresponding social risk/social need construct. 

RESULTS: Among 330,109 individuals, 248,808 (75%) completed the survey. In the lower response group (28,985; 9%), more patients were caregivers of children ≤ 4 years (18,231; 63%) and had commercial insurance (21,009; 72%) compared to the higher response group (23,873; 8% and 149,814; 50%, respectively). Factor analysis revealed a three-factor structure of the social risk/social need framework which we labeled: core resources, housing, and ability to work. From the magnitude of factor loadings, the items with the strongest indication of social risk/social need were paying for utilities, upcoming housing instability, and unemployment. 

CONCLUSION: In this health system, incomplete social risk/social need questionnaires are common. To improve response rates, the social risk/social need framework elucidated by our factor analysis will guide the development of a consolidated questionnaire for the EDs.