Area Deprivation Index and Magnitude of Scoliosis at Presentation to a Tertiary Referral Scoliosis Clinic in Massachusetts

Social Disadvantage and Transportation Insecurity in Clubfoot Clinic

OBJECTIVES

This study aims to evaluate the association of missing clubfoot clinic visits with transportation barriers and measures of socioeconomic status including the child opportunity index (COI).

METHODS

An 11-question survey was administered to caregivers of patients with clubfoot seen at a single pediatric tertiary hospital between August 2020 and September 2023. A chart review was conducted to obtain zip codes used to determine COI 2.0 scores. The impact of race/ethnicity, income, persons per household, COI, and transportation methods on missing at least one clinic visit was analyzed using descriptive and nonparametric statistics.

RESULTS

The transportation survey was completed by a total of 99 caregivers. The median travel time to the clinic was 45 minutes (IQR: 33, range: 1 to 180). Most participants reported use of a personal car (108/128, 83%), and 72% took time off work to attend the appointment. Those with lower COI had longer travel time ( P =0.02) and were less likely to use personal cars ( P =0.05). Missed clubfoot clinic visits were more common for families reliant on transportation other than a personal vehicle ( P =0.01) and those with annual income under $30,000 ( P =0.02).

CONCLUSIONS

Transportation insecurity was associated with greater social disadvantage as indicated by COI and more missed clinic visits.

LEVEL OF EVIDENCE

Level III.

Socioeconomic differences in access to scoliosis care in the pediatric population

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity affecting pediatric patients, with up to 10% requiring surgical intervention. Studies have shown disparities in these patients associated with race, ethnicity, and insurance type, but there is limited information on disparities that exist based on geographical parameters. In this study, we aim to explore the disparities in the care for AIS by looking at differences in the rates of readmission, infection, and revision between patients residing in rural and urban environments.

METHODS

This is a retrospective cohort study utilizing the Pediatric Health Information System. Pediatric patients that underwent posterior spinal fusion (PSF) for AIS from October 2015 to July 2022 were included. Diagnoses and procedures were identified based on ICD-10 codes and internal tools built into the database. Descriptive statistics were used to summarize the data, including demographics, infection rates, readmission rates, and revision rates. T tests, Chi-squared tests, and logistic regression were used to assess differences between the rural and urban populations. We utilized STATA/SE 15.1 for all data analysis.

RESULTS

15,318 patients were included in the final cohort. Demographics and baseline characteristics were similar between the rural and urban patients, although more rural patients used Medicaid over commercial insurance (41.5% vs. 32.7%, p < 0.01), median household income was lower in rural patients (p < 0.01), and there was a higher proportion of Hispanic patients in the urban patient cohort (13.9% vs. 6.4%, p < 0.01). Complication rates were not significantly different between the urban and rural patient cohorts, although rural patients did have a significantly higher 90-day readmission rate (7.3% vs. 6.1%, p = 0.03) and higher rates of instrumentation removal (7.7% vs. 4.9%, p = 0.01).

CONCLUSIONS

The surgical outcomes between rural and urban pediatric AIS patients undergoing PSF are comparable, although 90-day readmission rates and rates of instrumentation removal were higher in rural patients. Insurance status is likely a significant driver for the differences observed in this study. Future research is needed to better understand the reasons for these differences and to develop strategies to improve outcomes.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Greater Socioeconomic Deprivation Is Associated With Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures

OBJECTIVES

This study explored the hypothesis that social determinants of health, including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation of humeral shaft fractures.

METHODS

DESIGN

Retrospective.

SETTING

Single, academic, tertiary level I trauma center.

PATIENT SELECTION CRITERIA

Adults with midshaft humerus fractures (Orthopaedic Trauma Association/Association of Osteosynthesis 12) were treated operatively with plate fixation from May 2011 to May 2021 with a minimum follow-up of 9 months.

OUTCOME MEASURES AND COMPARISONS

Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. Social determinants of health were assessed using the Area Deprivation Index (ADI). Demographics, complication rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles.

RESULTS

One hundred ninety-six patients fit the study criteria. The average age of the cohort was 47 years with 100 women (51%). Comparisons of the least deprived quartile (n = 49) with the most deprived quartile (n = 49) yielded similar sex distribution (59% vs. 43% females, P = 0.15), fewer non-White patients (8% vs. 51%, P < 0.01), older average age (51 vs. 43 years, P = 0.05), similar body mass index (30.5 vs. 31.8, P = 0.45), and higher Charlson Comorbidity Index (2.2 vs. 1.1, P = 0.03). While nonunion rates were similar ( P = 0.20) between groups, the most deprived quartile had 2.3 times greater odds of postoperative complications ( P = 0.04). Patients in the most deprived group exhibited higher Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores ( P < 0.01) and PROMIS Depression (D) scores ( P = 0.01), with lower PROMIS Physical Function scores ( P < 0.01) at 6-month follow-up than the least deprived cohort. The most deprived cohort had 3 times higher odds of missing scheduled appointments within the first postoperative year ( P < 0.01), resulting in a significantly higher no-show rate ( P < 0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments ( P < 0.01), no-show rates ( P = 0.04), and experiencing one of the following postoperative complications during recovery: nonunion, radial nerve injury, or dysfunction ( P = 0.03).

CONCLUSIONS

Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation. These findings suggest that baseline socioeconomic disparities predict unfavorable postoperative outcomes even given favorable baseline health status according to the Charlson Comorbidity Index score.

LEVEL OF EVIDENCE

Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Are social determinants of health associated with an increased length of hospitalization after revision total hip and knee arthroplasty? A comparison study of social deprivation indices

INTRODUCTION

Length of stay (LOS) has been extensively assessed as a marker for healthcare utilization, functional outcomes, and cost of care for patients undergoing arthroplasty. The notable patient-to-patient variation in LOS following revision hip and knee total joint arthroplasty (TJA) suggests a potential opportunity to reduce preventable discharge delays. Previous studies investigated the impact of social determinants of health (SDoH) on orthopaedic conditions and outcomes using deprivation indices with inconsistent findings. The aim of the study is to compare the association of three publicly available national indices of social deprivation with prolonged LOS in revision TJA patients.

MATERIALS AND METHODS

1,047 consecutive patients who underwent a revision TJA were included in this retrospective study. Patient demographics, comorbidities, and behavioral characteristics were extracted. Area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) were recorded for each patient, following which univariate and multivariate logistic regression analyses were performed to determine the relationship between deprivation measures and prolonged LOS (greater than five days postoperatively).

RESULTS

193 patients had a prolonged LOS following surgery. Categorical ADI was significantly associated with prolonged LOS following surgery (OR = 2.14; 95% CI = 1.30-3.54; p = 0.003). No association with LOS was found using SDI and SVI. When accounting for other covariates, only ASA scores (ORrange=3.43-3.45; p < 0.001) and age (ORrange=1.00-1.03; prange=0.025-0.049) were independently associated with prolonged LOS.

CONCLUSION

The varying relationship observed between the length of stay and socioeconomic markers in this study indicates that the selection of a deprivation index could significantly impact the outcomes when investigating the association between socioeconomic deprivation and clinical outcomes. These results suggest that ADI is a potential metric of social determinants of health that is applicable both clinically and in future policies related to hospital stays including bundled payment plan following revision TJA.

Neighborhood socioeconomic disadvantages influence outcomes following rotator cuff repair in the non-Medicaid population

BACKGROUND

Prior investigations have utilized various surrogate markers of socioeconomic status to assess how health care disparities impact outcomes after rotator cuff repair (RCR). When taken as individual markers, these factors have inconsistent associations. Medicaid insurance status is an accessible marker that has recently been correlated with less optimal outcomes after RCR. Socioeconomic disparities exist within the non-Medicaid population as well and are arguably more difficult to characterize. The Area Deprivation Index (ADI) uses seventeen socioeconomic variables to establish a spectrum of neighborhood health care disparity. The purpose of this study was to determine the influence of neighborhood socioeconomic disadvantages, quantified by ADI, on 2-year patient reported outcome scores following RCR in the non-Medicaid population.

METHODS

A retrospective review of patients who underwent RCR from 2015 to 2020 was performed. All procedures were performed by a group of 7 surgeons at a large academic center. Patient demographics and comorbidities were collected from charts. Rotator cuff tear size was assessed from arthroscopic pictures. ADI scores were calculated based on patients' home addresses using the Neighborhood Atlas tool. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score with a minimum follow-up of 2 years. A linear regression analysis with covariate control for age and patient comorbidities was performed.

RESULTS

There were 287 patients with a mean age of 60.11 years. The linear regression model between ADI and 2-year ASES score was significant (P = .02). When controlling for both age and patient comorbidities, every 0.9-point reduction in ADI resulted in a 1-point increase in the ASES score (P = .03). Patients with an ADI of 8, 9, or 10 had lower mean 2-year ASES scores than those with an ADI of 1 (87.08 vs. 93.19, P = .04), but both groups had similar change from preoperative ASES score (40.17 vs. 32.88, P = .12). The change in ASES score at 2-years in our study surpassed all established minimal clinically important difference values irrespective of ADI.

CONCLUSION

Patients with greater levels of disparity in their home neighborhoods have worse final ASES scores at 2 years, but patients significantly improve from their preoperative state regardless of social disadvantages. This is the first study to the authors' knowledge that examines ADI and outcomes following RCR. Providers should be aware that patients with higher ADI scores may have inferior preoperative shoulder function. The results of this study support the utilization of primary RCR in applicable tears regardless of socioeconomic status.

A Framework for Studying Healthcare Equity in Adolescent Idiopathic Scoliosis: Scoping Review and Meta-Analysis of Existing Literature

INTRODUCTION

Health inequities remain a notable barrier for pediatric patients, especially in conditions such as adolescent idiopathic scoliosis (AIS), where the efficacy of nonsurgical treatment is dependent on early diagnosis and referral to a specialist. Social determinants of health (SDOH) are nonmedical factors that affect health outcomes, such as economic stability, neighborhood environment, and discrimination. Although these factors have been studied throughout the AIS literature, considerable inconsistencies remain across studies regarding the investigation of SDOH for this population. Through a scoping review, we analyze the existing literature to propose a comprehensive framework to consider when designing future prospective and retrospective studies of healthcare equity in AIS.

METHODS

A systematic review was executed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. A meta-analysis was performed for each reported SDOH (race, ethnicity, insurance provider, and socioeconomic status) including only studies with complete and consistent variables and outcomes. Cobb angle measurements were aggregated and summarized as the weighted mean difference with 95% confidence interval using a fixed or random-effects model (substantial heterogeneity identified).

RESULTS

Of 7,539 studies reviewed, nine studies met all the inclusion criteria. As expected, considerable inconsistencies were found across the nine studies making it difficult to aggregate data. Within the meta-analyses, the mean difference between White non-Hispanic and Hispanic patients was statistically significant (1.71; 95% confidence interval 0.78 to 2.65; P < 0.001). No other statistically significant differences were identified among the SDOH and presenting main Cobb angle magnitude.

CONCLUSION

These studies provide insight into healthcare inequities in AIS, although notable inconsistencies make it difficult to aggregate data and draw the conclusions needed to drive necessary public health changes. However, our proposed framework can provide a guideline for future prospective and retrospective studies to standardize data reporting and allow for improved collaboration, study design, and future systematic reviews and meta-analyses.

Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND

Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes.

METHODS

Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age.

RESULTS

Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes.

CONCLUSION

COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems.

LEVEL OF EVIDENCE

Level III-prognostic study.

Socioeconomic Status Correlates With Initial Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) Scores but Not the Likelihood of Spine Surgery

Objective To explore how socioeconomic status and patient characteristics may be associated with initial self-reports of pain and determine if there was an increased association with undergoing spine surgery. Methods Patients at an academic center between 2015 and 2021 who completed the Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) questionnaire were included. Multivariable linear regression models were used to determine the association between insurance type and patient factors with initial reports of pain. Multivariable logistic regression models were used to determine the association between PI and the likelihood of surgery in two time periods, three and 12 months. Results The study included 9,587 patients. The mean PROMIS-PI scores were 61.93 (SD 7.82) and 63.74 (SD 6.93) in the cervical and lumbar cohorts, respectively. Medicaid and Workers' Compensation insurance patients reported higher pain scores compared to those with private insurance: Medicaid (cervical: 2.77, CI (1.76-3.79), p<0.001; lumbar (2.05, CI (1.52-2.59), p<0.001); Workers' Compensation (cervical: 2.12, CI (0.96-3.27), p<0.001; lumbar: 1.51, CI (0.79-2.23), p<0.001). Black patients reported higher pain compared to White patients (cervical: 1.50, CI (0.44-2.55), p=0.01; lumbar: 1.51, CI (0.94-2.08), p<0.001). Higher PROMIS-PI scores were associated with a higher likelihood of surgery. There was no increased association of likelihood of surgery in Black, Medicaid, or Workers' Compensation patients when controlling for pain severity. Conclusion Black patients and patients with Medicaid and Workers' compensation insurance were likely to report higher pain scores. Higher initial pain scores were associated with an increased likelihood of surgery. However, despite increased pain scores, Black patients and those with Medicaid and Workers' Compensation insurance did not have a higher likelihood of undergoing surgery.

Impact of Social Determinants of Health on Adolescent Idiopathic Scoliosis Curve Severity

INTRODUCTION

Social determinants of health have been shown to influence the health and outcomes of pediatric patients. Adolescent idiopathic scoliosis (AIS) may be particularly sensitive to such factors as early diagnosis and treatment can obviate the need for surgical intervention. The purpose of this study was to analyze the effect that social determinants of health have on the severity of AIS at presentation and at the time of surgery.

METHODS

A retrospective review was conducted for consecutive patients who underwent posterior spinal fusion for AIS from 2020 to 2022. Demographic data was collected, while insurance status (private vs. public) and childhood opportunity index (COI) categories (LOW vs. HIGH) were used as a proxy for socioeconomic status. Curve magnitude at the initial presentation and at the latest preoperative visit were recorded with a threshold of 25 to 40 degrees considered within the bracing range. Univariate and multivariate analysis was done to compare differences between subgroups as appropriate.

RESULTS

A total of 180 patients with mean initial and preoperative major curve angles of 48 and 60 degrees were included. Statistically significant differences in race and insurance types were appreciated, with the LOW COI group having a higher proportion of underrepresented minority and publicly insured patients than the HIGH COI group ( P <0.001). Patients within the LOW COI group presented with an initial curve that was, on average, 6 degrees more severe than those within the HIGH group ( P =0.009) and a preoperative curve that was 4 degrees larger than those within the HIGH group ( P =0.015). Similarly, only 13% of patients within the LOW COI group presented with curves within the bracing threshold, compared with 31% in the HIGH COI group ( P =0.009).

CONCLUSION

Socioeconomic status plays a significant role in the severity of AIS. Specifically, patients with lower COI tend to present with curve magnitudes beyond what is responsive to nonsurgical treatment, leading to larger curves at the time of surgery. Future work should focus on addressing social inequalities to optimize the treatment and outcomes of AIS patients.

LEVEL OF EVIDENCE

Level III- Retrospective Comparative Study.

Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis

BACKGROUND

Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery.

METHODS

A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant.

RESULTS

The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004,  P = 0.001).

CONCLUSION

Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care.

LEVEL OF EVIDENCE

Level III; retrospective case-control study.

Socioeconomic disadvantage is correlated with worse PROMIS outcomes following lumbar fusion

BACKGROUND CONTEXT

Socioeconomic status (SES) has been associated with differential healthcare outcomes and may be proxied using the area-deprivation index (ADI). Few studies to date have investigated the role of ADI on patient-reported outcomes and clinically meaningful improvement following lumbar spine fusion surgery.

PURPOSE

The purpose of this study is to investigate the role of SES on lumbar fusion outcomes using Patient-Reported Outcomes Measurement Information System (PROMIS) surveys.

STUDY DESIGN/SETTING

Retrospective review of a single institution cohort.

PATIENT SAMPLE

About 205 patients who underwent elective one-to-three level posterior lumbar spine fusion.

OUTCOME MEASURES

Change in PROMIS scores and achievement of minimum clinically important difference (MCID).

METHODS

Patients 18 years or older undergoing elective one-to-three level lumbar spine fusion secondary to spinal degeneration from January 2015 to September 2021 with minimum one year follow-up were reviewed. ADI was calculated using patient-supplied addresses and patients were grouped into quartiles. Higher ADI values represent worse deprivation. Minimum clinically important difference (MCID) thresholds were calculated using distribution-based methods. Analysis of variance testing was used to assess differences within and between the quartile cohorts. Multivariable regression was used to identify features associated with the achievement of MCID.

RESULTS

About 205 patients met inclusion and exclusion criteria. The average age of our cohort was 66±12 years. The average time to final follow-up was 23±8 months (range 12-36 months). No differences were observed between preoperative baseline scores amongst the four quartiles. All ADI cohorts showed significant improvement for pain interference (PI) at final follow-up (p<.05), with patients who had the lowest socioeconomic status having the lowest absolute improvement from preoperative baseline physical function (PF) and PI (p=.01). Only those patients who were in the lowest socioeconomic quartile failed to significantly improve for PF at final follow-up (p=.19). There was a significant negative correlation between socioeconomic level and the absolute proportion of patients reaching MCID for PI (p=.04) and PF (p=.03). However, while ADI was a significant predictor of achieving MCID for PI (p=.02), it was nonsignificant for achieving MCID for PF.

CONCLUSIONS

Our study investigated the influence of ADI on postoperative PROMIS scores and identified a negative correlation between ADI quartile and the proportion of patients reaching MCID. Patients in the worse ADI quartile had lower chances of reaching clinically meaningful improvement in PI. Policies focused on alleviating geographical deprivation may augment clinical outcomes following lumbar surgery.