Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

A Higher Area Deprivation Index Is Associated With Increased Medical Complications and Emergency Department Utilizations After Total Hip Arthroplasty

BACKGROUND

The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. The purpose of this study was to determine whether patients undergoing total hip arthroplasty (THA) in areas of high ADI (greater disadvantage) were associated with differences in 90 days: 1) medical complications; 2) emergency department (ED) utilizations; and 3) readmissions.

METHODS

A nationwide database was queried for primary THA patients from 2010 to 2020. The ADI is reported on a scale of 0 to 100, with higher numbers indicating greater disadvantage. Patients undergoing primary THA in regions associated with high ADI (90%+) were compared to those of lower ADI (0 to 89%). A total of 138,670 patients were evenly matched between the two cohorts following 1:1 propensity score matching by age, sex, and Elixhauser Comorbidity Index. Primary endpoints were 90-day medical complications, ED utilizations, and readmissions. Multivariable logistic regression models calculated the odds ratios (ORs) and 95% confidence intervals (CIs). P values less than 0.01 were statistically significant.

RESULTS

Patients undergoing THA from high ADI had significantly higher rates and odds of developing any medical complications (13.0 versus 11.9%; OR: 1.09, P < 0.0001), including acute kidney injuries (1.8 versus 1.5%; OR: 1.20, P < 0.0001), myocardial infarctions (0.35 versus 0.24%; OR: 1.45, P = 0.0003), and surgical site infections (0.94 versus 0.76%; OR: 1.23, P = 0.0004). High-ADI patients had significantly higher rates and odds of ED visits within 90 days (3.94 versus 3.67%; OR: 1.08, P = 0.008). There was no significant difference in readmissions (5.44 versus 5.69%; OR: 0.95, P = 0.034).

CONCLUSIONS

Socioeconomically disadvantaged patients have increased odds of 90-days medical complications and ED utilizations, despite comparable 90-day readmission rates. Measures of neighborhood disadvantage may be valuable metrics to inform health care policy and improve postdischarge care.

Low socioeconomic indicators correlate with critical preoperative glenoid bone loss and care delays

BACKGROUND

Chronic and recurrent shoulder dislocations prior to stabilization can increase the risk of glenoid bone loss. Glenoid bone loss exceeding critical levels can lead to further instability and decreased outcomes following arthroscopic labral repair. Indicators of low socioeconomic status (SES), such as high Area Deprivation Index (ADI) and noncommercial insurance, are related to generalized delays to orthopedic care, which can cause recurrent instability and increase glenoid bone loss.

HYPOTHESIS

Higher national ADI and noncommercial insurance would be associated with greater levels of radiographic glenoid bone loss after glenoid instability.

METHODS

A retrospective study was performed with patients who underwent anterior labral repair. Chart review included demographics, course of care data, preoperative instability data, national ADI, and insurance status. The Neighborhood Atlas Website and patients' home addresses were used to obtain national ADI. Glenoid bone loss was measured using the best-fit circle Pico method on three-dimensionally aligned magnetic resonance images. Researchers were blinded to SES indicators during radiographic analysis. Glenoid bone loss was compared between SES indicators using one-way analysis of variance.

RESULTS

One hundred forty-six patients met inclusion criteria and had complete datasets (23.3% female; 22.4 ± 7.0-year-old; national ADI = 16.1 ± 15.3). Patients experienced on average 9.12 ± 6.63% glenoid bone loss. A curve fitting tool determined a quadratic nonlinear regression best characterized the association of glenoid bone loss and ADI (R2 = 0.392, P < .001). Individuals with commercial insurance experienced 8.58% ± 6.69% glenoid bone loss as compared to 11.78% ± 6.30% in individuals with Medicaid insurance (P = .03). Critical bone loss at a threshold of 13.5% was more likely with higher national ADI (P < .001) and Medicaid insurance (OR = 2.49, CI = 1.02-6.09). However, only national ADI was predictive of subcritical bone loss at a threshold of 10% (P < .001).

CONCLUSION

Patients with greater national ADI and Medicaid insurance status had greater rates of critical preoperative glenoid bone loss at a threshold of 13.5%. Greater national ADI is also predictive of subcritical glenoid bone loss at a threshold of 10% and overall glenoid bone loss. Further study is needed to assess the postoperative implications of these findings in this population.

Impact of Race and Social Determinants on Operative Management of Distal Radius Fractures in Medicare Patients

Background

Operative fixation of distal radius fractures (DRFs) in high-demand patients may provide functional benefit, particularly in the setting of significant displacement. Whether social determinants of health (SDOH) and race impact treatment remain unclear. The purpose of this study was to determine whether adverse SDOH modifiers and race are independent predictors of surgical intervention for DRF.

Methods

A retrospective analysis was conducted using the Medicare Standard Analytical Files of the PearlDiver database of patients with a DRF from 2007 to 2016. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOH variables were independent predictors of undergoing open reduction internal fixation (ORIF) within 3 weeks of a new diagnosis of DRF after controlling for age and fracture type.

Results

The average patient age was 76.3 years. A total of 10,697 (13.1%) patients underwent ORIF. Patients who underwent ORIF were less likely to have negative economic and social modifiers of SDOH and had lower odds of being non-White. Patients who underwent surgery also had higher odds of being younger, White, female, and having a type III open fracture.

Conclusions

In the Medicare population, non-White race and adverse economic and social modifiers of SDOH were independent predictors of undergoing nonoperative treatment of DRF after controlling for age and fracture type. Future studies are needed to further elucidate the nuanced effects of race and SDOH on the management of DRFs.

Lower socioeconomic status is correlated with worse outcomes after arthroscopic rotator cuff repair

BACKGROUND

Socioeconomic status has been recognized as a crucial social determinant of health influencing patient outcomes. Area Deprivation Index (ADI) is a validated measure of an area's socioeconomic status. Limited data exists on the impact of ADI and clinical outcomes and complications following rotator cuff repair (RCR). The purpose of this study was to investigate the impact socioeconomic factors have on outcomes following primary arthroscopic RCR.

METHODS

This is a retrospective cohort study with 1-year follow-up. Patients who underwent primary rotator cuff repair at a single institution from March 2014 to September 2022 were identified. Patient demographics, pre-and post-operative visual analog scale (VAS) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, range of motion, complications, and subsequent ipsilateral shoulder surgeries were collected. ADI was collected from an online mapping database using each patient's home address. Patients were split into ADI terciles, with ADI1 representing the least disadvantaged group and ADI3 representing the most disadvantaged group. Analysis of variance and T-test were used for continuous variables, and chi-square analyses were conducted for categorical variables.

RESULTS

In total, 467 patients underwent RCR and had complete demographic data and postoperative follow-ups over a year. There was a significant difference in race, with 78.2% of patients identifying as black in ADI3 and 18.1% in ADI1 (P < .001). Pre-operative PROMIS-Pain Interference, VAS, forward flexion, and abduction were significantly worse in ADI3 compared to ADI1 (P = .001, P < .001, P = .012, and P = .023). At one-year postoperative, patients in ADI3 scored significantly worse than patients in ADI1 in PROMIS- Upper Extremity score (P = .016), PROMIS- Pain Interference (P < .001), VAS (P < .001), forward flexion (P < .001) and abduction (P = .034). Higher ADI scores were associated with a positive correlation for pain (r = .258, P = < 0.001) a negative correlation with upper extremity function (r = - .233, P = .026), a positive correlation with pain interference (r = .355, P < .001), and negative correlation with forward flexion (r = - .227, P < .001). There were no significant differences in postoperative complications (P = .54), retears (P = .47), or reoperations rates (P = .22).

CONCLUSION

Lower socioeconomic status measured by ADI is associated with worse preoperative and 1-year postoperative pain, shoulder function, and range of motion following RCR. However, no differences were appreciated between cohorts regarding reoperation or complications.

LEVEL OF EVIDENCE III

Retrospective Cohort Study.

The impact of social deprivation on rotator cuff repair outcomes

BACKGROUND

Rotator cuff tears are a common orthopedic injury, and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair.

METHODS

We conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level 1 academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADIs, range of motion, visual analog pain scores, and patient-reported outcomes (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire [QuickDASH]) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using analysis of variance, t tests, χ2 tests, and univariate or multivariate logistic regression.

RESULTS

A total of 322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (P < .001). Massive tear occurrence was greater in the least deprived group (P = .003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH scores) were worse in the most deprived group compared with the least and intermediate deprived groups.

CONCLUSION

Social deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. Although clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

Neighborhood Deprivation and Association With Medical Complications, Emergency Department Use, and Readmissions in Shoulder Arthroplasty Patients

Background

Social determinants of health are prognostic indicators for patients undergoing orthopedic procedures.

Purpose

Using the area deprivation index (ADI), a validated, weighted index of material deprivation and poverty (a 0%-to-100% scale, with higher percentages indicating greater disadvantage), we sought to evaluate whether there are associations in shoulder arthroplasty patients between higher ADI and rates of (1) medical complications, (2) emergency department (ED) utilizations, (3) readmissions, and (4) costs.

Methods

We queried the PearlDiver nationwide database for patients who had undergone primary shoulder arthroplasty from 2010 to 2020. Patients from regions associated with high ADI (95%+) were 1:1 propensity matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 49,440 patients in total. Outcomes included 90-day complications, ED utilizations, readmissions, and costs. Logistic regression models computed odds ratios (ORs) of ADI on the dependent variables. P values of < .05 were significant.

Results

Patients from high ADI regions showed higher rates and odds of complications than those in the comparison group (10.84% vs 9.45%; OR: 1.10), including acute kidney injuries (1.73% vs 1.38%; OR: 1.23), urinary tract infections (3.19% vs 2.80%; OR: 1.13), and respiratory failures (0.49% vs 0.33%; OR: 1.44), but not increased ED visits (2.66% vs 2.71%; OR: 0.99) or readmissions (3.07% vs 2.96%; OR: 1.03). Patients from high ADI regions incurred higher costs on day of surgery ($8251 vs $7337) and at 90 days ($10,999 vs $9752).

Conclusions

This 10-year retrospective database study found that patients from high ADI regions undergoing primary shoulder arthroplasty had increased rates of all 90-day medical complications, suggesting that measures of social determinants of health could inform health care policy and improve post-discharge care in these patients.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient

BACKGROUND

Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care.

METHODS

A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant.

RESULTS

High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI.

CONCLUSIONS

Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.

LEVEL OF EVIDENCE

III.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment

Purpose

Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated.

Methods

This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex.

Results

In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level.

Conclusions

High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment.

Type of Study/Level of Evidence

Therapeutic III.

Race and Area of Deprivation Index Predict Outcomes of Endoscopic Sinus Surgery for Chronic Sinusitis

OBJECTIVE

The purpose of this study is to characterize the presentation, outcomes, and barriers to care for White and non-White patients undergoing endoscopic sinus surgery (ESS).

BACKGROUND

ESS is often successful in providing long-term relief for patients suffering from chronic rhinosinusitis (CRS). Literature that uses robust measures of socioeconomic status (SES) and barriers to care to assess ESS outcomes is limited.

METHODS

A retrospective matched cohort study of patients who underwent ESS for CRS between 1/1/2015 and 6/1/2021 at a single tertiary care academic center was conducted. White and non-White patients were matched 1-to-1 by sex and age (± 5 years). SES was evaluated using the area of deprivation index (ADI).

RESULTS

Of the 298 patients included in the study, 149 are White and 149 are non-White, 111 (37.2%) have CRS with nasal polyposis (CRSwNP), 141 (47.3%) had allergic rhinitis, 90 (30.2%) had asthma and 22 (7.4%) required revision ESS. Non-White patients were 3.62 times more likely to present with CRSwNP (95% confidence interval [CI] 2.2-5.96) and had 2.87 times increased odds for requiring revision ESS than age and sex-matched White patients (95% CI 1.090-7.545). The median ADI for non-White (6.00) patients was higher than for White patients (3.00) (P < .001) and 21.5% more non-White patients presented with Medicaid (P < .001).

CONCLUSION

Non-White patients undergoing ESS for CRS are more likely to present from areas with fewer resources and be underinsured. Using robust measures of SES, such as ADI, may allow for care to be tailored to patients with barriers to care.

Missed Short-term Follow-up After Arthroscopic Rotator Cuff Surgery: Analysis of Surgical and Demographic Factors

INTRODUCTION

Few current studies have examined loss to follow-up after rotator cuff-related shoulder arthroscopy. Understanding the demographic and surgical factors for missed follow-up would help identify patients most at risk and potentially mitigate the onset of complications while maximizing clinical outcomes.

METHODS

A retrospective review of consecutive rotator cuff arthroscopic procedures with a minimum of 12-month follow-up done by a single, fellowship-trained surgeon was undertaken from February 2016 through January 2022. Demographic patient and surgical data, including age, sex, marital status, self-identified race, and body mass index, were collected. Follow-up at ≤3, 6 weeks, 3, 6, and 12 months was determined. Patient-related and surgical predictors for missed short-term follow-up, defined as nonattendance at the 6 and 12-month postoperative visits, were identified.

RESULTS

There were 449 cases included, of which 248 (55%) were women. The median age was 57 years (interquartile range [IQR], 51 to 62). Patients with commercial insurance (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.23 to 0.64; P < 0.001) or workers' compensation (OR, 0.15; 95% CI, 0.05 to 0.43; P < 0.001) were less likely to miss the 6-month follow-up compared with patients with Medicare, whereas increased socioeconomic deprivation (OR, 0.86; 95% CI, 0.77 to 0.97, P = 0.015) was associated with decreased odds of missing that visit. Patients who missed the ≤3 weeks (OR, 1.77; 95% CI, 1.14 to 2.74, P = 0.010) and 3-month (OR, 8.55; 95% CI, 4.33 to 16.86; P < 0.001) follow-ups were more likely to miss the 6-month follow-up. Use of a patient contact system (OR, 0.55; 95% CI, 0.35 to 0.87, P = 0.01) and increased number of preoperative visits (OR, 0.91; 95% CI, 0.84 to 0.99, P = 0.033) were associated with decreased odds of missing the 12-month follow-up. Patients who missed the 6-month follow-up were more likely to miss the 12-month follow-up (OR, 5.38; 95% CI, 3.45 to 8.40; P < 0.001).

CONCLUSION

Implementing an electronic patient contact system while increasing focus on patients with few preoperative visits and who miss the 6-month follow-up can reduce the risk of missed follow-up at 12 months after shoulder arthroscopy.