Abstract
Background:
Cystic fibrosis (CF) outcomes are influenced by a myriad of genetic, microbiological, and environmental factors, as well as socioeconomic constraints. Studies have shown that low socioeconomic status is associated with a higher risk of death, lower body weight and height, worsened pulmonary function, and increased pulmonary exacerbation in children with CF. Screening for social risk factors (SRFs) is one possible approach to help mitigate unmet social needs in people with CF (PwCF).
Objectives:
Does a positive screening response for SRF correlate with health outcomes in PwCF?
Design:
This is a single-center, retrospective analysis of outcomes in adult PwCF. The study includes data from 2021 to 2022.
Methods:
A social needs screening tool was administered to identify SRF in PwCF in eight domains: housing, food, transportation, utilities, healthcare cost, medication cost, income/employment, and education. A total of 121 PwCF were included in the analysis. Linear mixed-effects models, Poisson regression, and mixed-effects Cox regression were used for analyses of multivariate models.
Results:
When adjusted for multiple covariables, PwCF who screened positive for SRF had similar lung function and BMI as PwCF who reported no SRF and an increased CF exacerbation rates per person/per year when compared to their peers, 1.700 (1.275, 2.266) versus 0.829 (0.608, 1.130) (p = 0.006). Adjusted models showed that the median time to exacerbation was significantly lower in PwCF who screened positive for SRF (210 days vs 389 days).
Conclusion:
PwCF who responded positively for SRF experienced an increased rate of CF exacerbation, and this finding remained significant when adjusted for multiple variables, including new CF medications. Medication cost, income/employment concerns, and food insecurity emerged as the most significant predictors of exacerbation rates and time to the next exacerbation. Further studies are needed to evaluate effective interventions and resources to mitigate SRF.
Keywords
Introduction
Existing literature has demonstrated disparities in cystic fibrosis health outcomes related to social determinants of health (SDOH). Low socioeconomic status (SES) has been shown to be associated with factors such as a higher risk of death, lower body weight and height, worsened pulmonary function, and increased need for treatment for a pulmonary exacerbation in children with cystic fibrosis (CF).1–6 These discrepancies in weight percentiles and pulmonary function persist into adulthood. In adulthood, accelerated lung function decline is also associated with public insurance use. 7 Longitudinally, minoritized status and low SES may impact clinical and health-related quality of life outcomes of CF patients across their lifespan. 8 One longitudinal cohort study accounted for air pollution and respiratory hazards, green space, crime, and socioeconomic deprivation. Those whose lung function declined earliest tended to live in places with higher levels of air pollution, community deprivation, and crime compared to their counterparts who declined later. 9
While SDOH often refers to community-level social and economic conditions, social risk factors (SRF) refer to the individual level and are defined as, “specific adverse social conditions that are associated with poor health.” 10 SDOH and SRFs may interact to impact individuals. For example, the neighborhood where a person lives may have limited access to affordable groceries, and an individual may be unable to afford to afford adequate amounts of food, resulting in food insecurity. Food insecurity in PwCF is associated with lower body mass index (BMI) or weight-for-length percentiles, decreased airway clearance and medication adherence, and worse mental health outcomes.11–13 In one 2019 study of 1800 PwCF in the United States, 33% reported experiencing food insecurity. 14 In the same study, 26% reported housing issues, 24% were unable to meet prescription needs due to cost, and 10% delayed or skipped care center visits due to the cost of care. 14 In one study of a pediatric pulmonary clinic, health insurance concerns in CF patients were linked with poorer pulmonary function and more hospitalizations. 15
Given research indicating both the prevalence of SRFs and their impact on the health outcomes of PwCF, strategies to address these health disparities have been proposed. One possible avenue involves screening PwCF for SRF and connecting PwCF who request assistance to resources to address unmet needs. The UVA Health Adult Cystic Fibrosis Center began screening for social risks in 2020. The study showed that 28.9% of PwCF indicated at least one new positive risk factor in the screening questionnaire due to the COVID-19 pandemic. 16 The screening tool used in this study was adapted and tested in 2021 for use in routine care to screen SRFs in eight domains: housing, food, transportation, utilities, healthcare access, medication access, income/employment status, and education level. 17 Of the CF patients surveyed, in 2021, 42.4% screened positive for at least one risk factor across all versions of the screening tool. 17 Building on this prior work, the present study aimed to evaluate the association between positive screening responses to SRFs and health outcomes, including BMI, lung function, and pulmonary exacerbation frequency, in a cohort of adults with CF.
Methods
This is a single-center retrospective cohort study of 121 adult patients with Cystic Fibrosis conducted at the University of Virginia Medical Center during 2021–2022 to assess the impact of social risk domains on BMI; percent predicted forced expiratory volume in 1 second (FEV1pp), and rate of pulmonary exacerbations. The screening was conducted in 2022. It was administered via three modalities: a paper instrument during in-person visits, screen sharing during telehealth visits, and a secure online survey sent through MyChart. The tool assessed SRF across eight domains: housing, food, transportation, utilities, healthcare access, medication access, income/employment status, and education level. Respondents were asked at the end of the screening whether they would like to receive help with any of these concerns. All individuals who requested help were contacted by the program social worker and provided with social resources. The screening tool was developed locally by the UVA adult CF care team and tailored to the needs of PwCF, and it was chosen over national instruments like the CMS HRSN tool to better align with CF-specific care processes and ensure relevance to the unique challenges faced by this population, with particular emphasis on the financial aspects that could influence access to treatments, medications, and CF care. The development of the survey, as well as the screening and intervention process, is described elsewhere.16,17 In 2022, 143 of 150 (95.3%) eligible adult PwCF followed at our center completed the SRF screening. Of the 143 individuals who completed the screening, 121 had complete outcome data available for BMI, lung function (FEV1pp), and pulmonary exacerbation frequency, and were included in the final analysis cohort. No additional eligibility criteria were applied. Due to the low number of positive responders to the education SRF, we did not perform statistical analysis related to this domain. Analyses included categorical and longitudinal variable data from 2021 to 2022.
Study data were collected using the Cystic Fibrosis Foundation (CFF) patient registry and a Caboodle data haul (Epic’s data management system used to extract large amounts of patient data from the medical record). SRF data were collected from a questionnaire completed by patients in 2022. Race, ethnicity, sexual orientation, and gender variables were collected from a patient-reported demographic survey and used in multivariate models. Numbers less than 5 are not reported in the tables to maintain PwCF privacy. BMI is reported as a mean, calculated as the average of all values per patient, averaged per group of interest. FEV1pp mean is reported as the average of all values per patient, averaged per group of interest. FEV1pp was calculated retrospectively using the Global Lung Initiative 2023 formula. 18 Demographic information between positive responders to any social risk domain and negative responders to all was compared using a two-sample t-test for numerical variables and a chi-squared test of independence for categorical variables.
Longitudinal data for BMI and FEV1pp were analyzed with an unadjusted and then an adjusted linear mixed-effects model regressing BMI or FEV1pp against each social risk domain, including a random intercept for each adult with CF, and adjusting for multiple variables: age, gender, pancreatic insufficiency, cystic fibrosis transmembrane regulator (CFTR) mutation, asthma, allergic bronchopulmonary aspergillosis (ABPA), use of Trikafta, CF-related diabetes, methicillin-resistant Staphylococcus aureus (MRSA) colonization, Pseudomonas spp. colonization, race, ethnicity, employment status, insurance type, sexual orientation, and educational attainment. These variables were used in all multivariate models throughout all analyses. Inference on model coefficients, contrasts, and construction of 95% confidence intervals were performed with Wald-type inference. p < 0.05 was designated as the significance level. Additionally, a categorical analysis was performed to look into how the distribution of BMI categories (underweight/normal weight/overweight/obese) and lung function categories based on FEV1pp (normal as ppFEV1 >90, mild as ppFEV1 70–90, moderate as ppFEV1 40–70, and severe as ppFEV1 <40) differed between positive and negative responders to SRFs.
Pulmonary exacerbation frequency was analyzed with two approaches. The first approach employed Poisson regression to estimate the annual exacerbation rate between positive and negative responders to the domains of social risk. The second approach to analyzing pulmonary exacerbation frequency involved recurrent events survival analysis to characterize how social risk domains influence the exacerbation risk at the individual patient level. All models were first fit as an unadjusted, univariate model, followed by a multivariate model. There were a total of 271 exacerbation events during the study period. Exacerbations were defined based on clinical documentation in the medical record as absent, mild, moderate, or severe, based on symptom burden, based on modified Fuchs criteria, ppFEV1 decline, and treatment intensity (e.g., need for oral, inhaled, or intravenous antibiotics, or hospitalization). This classification of exacerbation severity is distinct from the stratification of CF lung disease based on lung function by ppFEV1 (normal as ppFEV1 >90, mild as ppFEV1 70–90, moderate as ppFEV1 40–70, and severe as ppFEV1 <40). If some care episodes were not paired with the clinic visits, we included only the ones outside of the 2 weeks post-exacerbation. For each exacerbation of every patient, a time variable, defined as the number of days since the previous exacerbation, was calculated. A significance level of p < 0.05 was chosen. Multivariate, mixed-effects Cox regression models were fit with the survival and coxme packages in R (version 4.2.0), regressing time to next exacerbation over positive response to each social risk domain. These models included a random effect for each adult with CF and adjusted for the same variables as above. Additionally, for each exacerbation event, our models adjusted for that patient’s previous number of exacerbations to account for the increased risk of subsequent exacerbations. Inferences on regression coefficients, contrasts, and construction of 95% confidence intervals were performed with Wald-type inference. p < 0.05 was designated as the significance level. Covariate-adjusted survival curves were plotted with the adjusted Curves package in R.
IRB approval was obtained from the organization prior to conducting the study (IRB-HSR #18798). The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. 19
Results
Demographics
Detailed demographic characteristics are summarized in Table 1. A total of 121 PwCF were included in the analysis, with a mean age of 34.7 years, and 50.4% were male. Among participants, 88.5% had at least one F508del mutation, 81% were on highly effective modulator therapy with elexacaftor/tezacaftor/ivacaftor (ETI), and 41 (33.9%) screened positive for at least one SRF. Of these 41, 19 reported concerns with housing, 14 with food, 6 with transportation, 16 with healthcare cost, and 14 with medication cost. Positive responders to any SRF differed significantly from those who reported no SRFs with respect to insurance type, educational attainment, prevalence of colonization by Pseudomonas, and prevalence of ABPA. Compared to those who reported no SRFs, positive responders to any were more likely to carry public insurance, to not have a college degree, to be colonized with Pseudomonas, and to have ABPA.
Demographics and characteristics.
p < 0.050.
Numbers less than 5 are not reported to protect patient privacy.
CF, cystic fibrosis; CFTR, cystic fibrosis transmembrane regulator; FEV1pp, percent predicted FEV1; PwCF, people with cystic fibrosis; SRF, social risk factors.
The unadjusted comparisons of mean BMI identified no significant differences between positive and negative responders, for all SRF domains (Figure 1(a)). This was corroborated by multivariate models, which also found no significant differences in mean BMI even adjusting for covariates (Supplemental Table 1).
Comparison of (a) mean BMI and (b) mean FEV1pp between positive responders and negative responders to social risk factor domains. FEV1pp was calculated using Global Lung Initiative 2023 formula. Means and 95% confidence intervals were estimated by unadjusted linear mixed-effects models with random intercepts for each adult with CF.
For the unadjusted comparisons for mean FEV1pp, differences were observed between positive and negative responders (Figure 1(b)). Interestingly, PwCF who screened positive for at least one SRF had a numerically lower mean FEV1pp than those who reported no SRFs (71.2% vs 76.5%, p = 0.067), a trend that did not reach statistical significance. Similarly, another statistically insignificant trend was observed in relationship with food insecurity, wherein positive responders tended to have lower FEV1pp than negative responders (69.7% vs 75.4%, p = 0.352). While both were statistically insignificant, their general trend toward lower FEV1pp in positive responders are clinically significant and may warrant further investigation in larger cohorts. However, statistically significant differences decrease in FEV1pp were noted with positive response to healthcare cost concerns (64.5% vs 76.3% FEV1pp, p = 0.041) and medication cost concerns (57.7% vs 77.0% FEV1pp, p = 0.002). When adjusting for covariates, no statistical significance was found, suggesting that additional factors play a role in these differences (Supplemental Table 2).
When separated into individual social risk domains, there was a large heterogeneity in BMI and FEV1pp values between the interest groups (Figure 2). Food security, medication cost, transportation, and utilities concerns stood out. For food insecurity, 2.8% of negative responders versus 7.1% of positive responders had a BMI of less than 18.5, and 6.5% versus 21.4% had an FEV1pp less than 40. For concerns related to medication cost, 7.5% of negative responders compared to 14.3% of positive responders had an FEV1pp less than 40. A similar pattern was noted for positive responders to income/employment concerns and transportation concerns, of whom a larger percentage had an FEV1pp below 70, at 75.0% and 66.7%, compared to negative responders (40.1% and 40.0%). For utilities concerns, only 2.6% of negative responders had a BMI of less than 18 compared to 25% of positive responders, and 7.7% compared to 25% had an FEV1pp less than 40. Overall, 75%–85% of positive responders to concerns related to medication cost and healthcare cost were, on average, in the moderate to severe range for FEV1pp across both years 2021–2022 (compared to ~35% for negative responders). Due to small sample size for certain SRF domains, a statistical analysis was not performed.
Comparison of the proportion of positive and negative responders to each social risk domain who were, on average across both years 2021–2022, (a) underweight/normal weight/overweight/obese and (b) had FEV1pp in the severe/moderate/mild/normal range.
Differences in exacerbation rate
PwCF with SRFs demonstrated significantly higher exacerbation rates compared to those without SRFs (Table 2). The adjusted annual exacerbation rate was 1.687 times higher (95% CI: (1.163, 2.448), p = 0.006) in those screening positive for any SRF. Notably, participants reporting food insecurity and medication cost concerns had exacerbation rates 2.436 (95% CI: (1.554, 3.817), p < 0.001) and 1.738 (95% CI: (1.079, 2.801), p = 0.023) times higher, respectively, than their counterparts without these concerns. Income/employment concerns were also significant, with positive responders experiencing an annual exacerbation rate 1.946 times higher (95% CI: (1.075, 3.523), p = 0.028) than negative responders.
Comparison of the mean annual rate of exacerbations (exacerbations per year) in positive versus negative responders of social risk factor domains, with 95% confidence intervals.
Models adjusted for age, gender, pancreatic insufficiency, CFTR mutation, asthma, allergic bronchopulmonary aspergillosis, elexacaftor/tezacaftor/ivacaftor use, Pseudomonas and MRSA colonization, CF-related diabetes, race, ethnicity, employment status, health insurance type, sexual orientation, education attainment, BMI, and lung function.
p < 0.050. **p < 0.010. ***p < 0.001.
BMI, body mass index; CF, cystic fibrosis; CFTR, cystic fibrosis transmembrane regulator.
PwCF who screened positive for any SRF domain, for food insecurity, and for concerns with medication cost were significantly associated with increased individual risk of pulmonary exacerbation. The relative risk of pulmonary exacerbation was 1.772 (95% CI: (1.111, 2.827), p = 0.016) for positive response to any domain of social risk, 3.483 (95% CI: (1.860, 6.520), p < 0.001) for positive response to food insecurity, and 2.260 (95% CI: (1.141, 4.476), p = 0.019) for medication cost (Table 3). Reflecting the increased exacerbation risk, the median number of days from the previous pulmonary exacerbation to the next was, overall, 389 days in PwCF without SRFs versus 210 days in PwCF who screened positive for any SRF domain. Similarly, for food insecurity, the median number of days to the next exacerbation was 399 days in negative responders versus 112 days in positive responders. For medication cost concerns, negative responders had a median of 312 days until the next exacerbation versus 147 days in positive responders (Figure 3). While a positive response to concerns with income/employment was associated with a 115.8% higher risk of pulmonary exacerbation (95% CI: (0.956, 4.873), p = 0.064), it was not statistically significant. Still, the median time between exacerbations was 141 days for positive responders to income/employment concerns, compared to 259 days in negative responders.
Results of the Cox frailty models: the association of exacerbation risk with positive response to any domain of social risk and with each individual domain.
The risk ratio represents the relative risk of exacerbation in positive responders of each domain with respect to negative responders. Models adjusted for age, gender, pancreatic insufficiency, CFTR mutation, asthma, allergic bronchopulmonary aspergillosis, elexacaftor/tezacaftor/ivacaftor use, Pseudomonas and MRSA colonization, CF-related diabetes, race, ethnicity, employment status, health insurance type, sexual orientation, education attainment, BMI, lung function, and the number of previous exacerbations.
p < 0.050. ***p < 0.001.
BMI, body mass index; CF, cystic fibrosis; CFTR, cystic fibrosis transmembrane regulator.
Adjusted cumulative incidence of the next pulmonary exacerbation in adult PwCF who responded positively to (a) any social risk factors, (b) food insecurity, and (c) medicine cost concerns.
Discussion
This study is the most comprehensive examination of SRF and its impact on health outcomes in adult PwCF in the era of highly effective CFTR modulators like Ivacaftor and ETI. It includes eight SRF domains and analyzes these SRF domains’ interactions with health outcomes. The study demonstrates that adults with CF who screened positive for one or more SRFs experienced a significantly higher burden of pulmonary exacerbations and shorter time to the next exacerbation compared to their counterparts without SRFs, even after adjusting for clinical and demographic covariates. These findings support the hypothesis that health outcomes in PwCF are influenced by the presence of SRFs.
When adjusted for multiple variables, BMI and lung function (FEV1pp) did not differ significantly between groups. However, the exacerbation-related outcomes were particularly sensitive to SRF, emphasizing the potential impact of social risk factors on acute disease progression rather than steady-state clinical measures. By looking more granularly into specific social risk domains, medication cost, income/employment concerns, and food insecurity emerged as the most significant predictors of exacerbation rates and time to the next exacerbation. SES may be impacted by income/employment status.
Existing literature has consistently shown that food insecurity, inability to afford prescriptions, and lower socioeconomic status are associated with poorer health outcomes in PwCF, so our results do not come as a surprise. However, much of this research has relied on area-level indicators such as ZIP code-based metrics or administrative proxies that may not fully reflect individual patients’ lived experiences or real-time social challenges. In contrast, our study used a standardized, point-of-care screening tool to directly assess patient-reported SRFs across eight domains. This individualized, contemporaneous approach provides a more actionable and patient-centered understanding of unmet needs, offering new insight into how specific social barriers relate to disease burden in the era of CFTR modulators.
Access to effective medication is a critical component of maintaining optimal health, particularly for individuals with CF who are now eligible for therapies targeting the underlying protein defect responsible for the disease. ETI has revolutionized treatment for approximately 90% of adults with CF, demonstrating a 63% reduction in pulmonary exacerbations in clinical trials compared to placebo. 20 When CFTR modulators emerged as a new medication in CF, they were perceived as universal panaceas. Despite the transformative potential of ETI, disparities in access to ETI, including cost-related barriers, persist. Up to 6% of PwCF continue to have frequent exacerbations despite being prescribed and eligible to ETI. 21 Approximately 5% of PwCF do not qualify for ETI. Understanding the pathophysiology behind exacerbations in the era of ETI is important to improve outcomes for all PwCF. Furthermore, understanding the cost barriers to these medications and implications in health outcomes is paramount. From this study, the association between medication cost concerns and increased exacerbations underscores the need for systemic interventions to ensure equitable access to these life-changing therapies.
Employment status also plays a pivotal role in health outcomes, disease management, and quality of life for PwCF. In our study, individuals with income/employment-related SRFs experienced exacerbation rates that were twofold higher. Employed PwCF typically report higher levels of physical functioning, role participation, and emotional well-being compared to their nonemployed counterparts.22,23 The structured routines, supportive social networks, and financial stability provided by employment likely contribute to healthier lifestyles and better disease management. Promoting workplace participation and addressing barriers to employment for PwCF could serve as an impactful strategy to improve both physical and mental health outcomes.
PwCF reporting food insecurity experienced a more than twofold increase in annual exacerbation rates and had an overall median time to the next exacerbation nearly four times shorter than those without food insecurity. These results align with prior research, suggesting that limited access to adequate nutrition and necessary medications can exacerbate disease severity by reducing the ability to maintain optimal nutritional status and adhere to prescribed treatments among children and adults with CF, while infrequent food screenings are linked to a greater risk of underweight status in pediatric patients. 12 Addressing food insecurity stands out as a particularly urgent need given its association with both nutritional and pulmonary outcomes in PwCF. Weight is a critical factor influencing outcomes in cystic fibrosis, as insufficient weight is linked to poorer pulmonary function and reduced survival. 24 These findings emphasize the necessity of implementing standardized food insecurity screenings alongside resources to enhance nutrition and improve clinical outcomes for PwCF.
It is interesting that statistically significant associations between negative health outcomes and SRFs did not emerge for all eight domains of social risk. This may be due to limitations of this study and challenges inherent to studying SRFs. This study included a total of 121 individuals, resulting in a relatively small sample size for individual SRF domains, as well as for certain demographic groups, which existing literature has demonstrated to experience health disparities in CF outcomes. This limited the statistical power to detect significant associations, potentially underestimating the true impact of these factors on health outcomes. The lack of significant differences in BMI and FEV1pp between PwCF with and without SRFs may reflect the small sample size. In addition, the study groups were very small when further analyzed by BMI categories and FEV1pp disease severity. Finally, SDOH and SRF are multifactorial and interconnected. Some study variables, such as age, gender, race, ethnicity, employment status, health insurance type, sexual orientation, and educational attainment, may have accounted for differences in BMI and FEV1pp, reducing the effect of SRFs in our linear models.
One other possibility is that the impact of standardized interventions provided by the care team may have impacted disparities in long-term outcomes such as weight and lung function. This study was performed by a team that included a social worker, a pharmacist, a nurse coordinator, and two physicians, who designed and implemented multiple standardized quality improvement processes to address access to care, and mitigate positive SRFs, including access to CF therapies in general and to CFTR modulators in particular and ensure continuity of treatment. It is possible that PwCF seen at CF programs with less infrastructural support may have unaddressed concerns related to CFTR modulator access and may experience worse outcomes. In addition, the social mechanism to mitigate social risks can be scarce or nonexistent within certain communities or neighborhoods, and location of CF centers and the PwCF they serve may play a significant role in association between SRFs and negative health outcomes.
The persistence of disparities in exacerbation outcomes suggests that SRFs may act as acute stressors that exacerbate disease flares and result in greater utilization of acute care, potentially due to barriers in accessing timely routine care or lack of access to resources during exacerbation-prone periods.
Nevertheless, the reliance on self-reported data for SRFs introduces the possibility of reporting bias, as individuals may underreport or overreport their social challenges due to stigma or misinterpretation of survey questions. Previous evidence from food insecurity screening suggests that disclosure rates may vary depending on the method of administration, with written, self-administered tools sometimes yielding higher disclosure than verbal, in-person screening. 25 Although not directly studied in SRF screening, this finding underscores that the choice of screening modality may itself influence reporting, potentially amplifying or mitigating bias depending on the population and context. These factors, in combination with our single-center design, limit the generalizability of our findings, as they may not be representative of broader PwCF populations with different demographic/socioeconomic characteristics or screening modalities. Future studies should aim to include larger, multicenter cohorts to validate and expand upon these findings.
The interventions provided by the study team represent an important step toward addressing unmet social needs as part of standardized CF care. However, access to resources varies widely depending on geographic location, community infrastructure, and available funding. Sustainable change will require not only the integration of tailored interventions, such as food assistance, medication subsidies, and employment support, into routine CF care, but also continued advocacy for expanded state and federal support. Importantly, these efforts must be responsive to the specific challenges faced by different CF populations, recognizing that the social barriers impacting health are not uniform. Collaborative advocacy involving patients, providers, researchers, and policymakers is essential to ensure that all PwCF can benefit equitably from advances in care and experience improved outcomes.
Conclusion
This study highlights the impact of SRF on health outcomes in adults with cystic fibrosis and emphasizes the importance of integrating routine SRF screening and tailored interventions into CF care. Standardized, QI-driven, SRF screening identified positive domains of social risk. Positive response for any SRF is associated with increased pulmonary exacerbations, a higher risk of exacerbations, and overall, a shorter median time to the next exacerbation. Food insecurity and medicine cost concerns were the two SRF domains most significantly associated with increased exacerbation frequency and shorter time to exacerbation. Targeted advocacy and tailored resource allocation are essential to mitigating the effects of these disparities and improving health outcomes for all individuals with CF. Further research is necessary to evaluate the long-term effectiveness of interventions and resources to mitigate SRFs.
Supplemental Material
sj-docx-2-tar-10.1177_17534666251393070 – Supplemental material for Social risk factors in patients with cystic fibrosis: impacts on exacerbations, lung function, and BMI
Supplemental material, sj-docx-2-tar-10.1177_17534666251393070 for Social risk factors in patients with cystic fibrosis: impacts on exacerbations, lung function, and BMI by Zhuoyi Galvin Li, Deirdre Jennings, Lindsay Somerville, Sriyaa Suresh, Rhonda List, Kevin Lonabaugh, Margaret Mercante, Kasey Wilburn, Alexis Wiggins, Aaron Smith, Andrew Barros and Dana P. Albon in Therapeutic Advances in Respiratory Disease
Supplemental Material
sj-pdf-1-tar-10.1177_17534666251393070 – Supplemental material for Social risk factors in patients with cystic fibrosis: impacts on exacerbations, lung function, and BMI
Supplemental material, sj-pdf-1-tar-10.1177_17534666251393070 for Social risk factors in patients with cystic fibrosis: impacts on exacerbations, lung function, and BMI by Zhuoyi Galvin Li, Deirdre Jennings, Lindsay Somerville, Sriyaa Suresh, Rhonda List, Kevin Lonabaugh, Margaret Mercante, Kasey Wilburn, Alexis Wiggins, Aaron Smith, Andrew Barros and Dana P. Albon in Therapeutic Advances in Respiratory Disease
Footnotes
References
Supplementary Material
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