CORR Insights®: Social Determinants of Health and Patients With Traumatic Injuries: Is There a Relationship Between Social Health and Orthopaedic Trauma?

Where Are We Now?

It’s well taught in surgical training that “trauma is a chronic disease” and “trauma is not random,” which is to say that it is not uniformly experienced across all members of society. This pattern of repeat presentations for separate injuries is sometimes called trauma recidivism [14], though the word recidivism connotes criminality, and its use should be reconsidered. Labeling it as such also focuses on patient behavior, obscuring the societal factors that influence health outcomes. These social determinants of health (SDOH) are the systems and conditions in which people are born, grow, work, play, and age. They can be divided into factors of economic stability, education, social context and community, healthcare, and the built environment.

There is a growing body of research studying SDOH and health disparities in orthopaedic patient populations. The results, though seldom surprising, are disheartening and infuriating. A large cross-sectional analysis in St. Louis showed that patients presenting to sports medicine providers were less likely to be from ZIP Codes with a higher Social Deprivation Index, whereas the opposite was shown for patients presenting for trauma care. Furthermore, patients from ZIP Codes with the highest Social Deprivation Index scores reported higher baseline levels of pain interference, depression, and anxiety, and lower levels of physical function [15]. Access to care varies widely based on income, insurance status, educational attainment, geographic location, and more. For example, one study found that nearly half of patients with Medicaid insurance or no insurance who had been refused by local orthopaedic surgeons were unable to drive to a tertiary center because of limited personal resources [5]. In pediatric orthopaedics, children who were uninsured or publicly insured tended to present for care later in the disease course or after injury and to have difficulty accessing care such as scheduling appointments or obtaining necessary diagnostic imaging. These findings have been confirmed in patients with ACL or meniscal tears, tibial spine fractures, and upper extremity injury [2]. Even after access to care has been established, disparities in outcomes have been correlated with social determinants. There are ripple effects far beyond hospitalization and treatment. For example, racial, ethnic, and insurance disparities exist in access to posthospitalization rehabilitation for people who have experienced violence [9]. We also know from the LEAP study group that there are substantial unmet social support service needs in the year after severe lower extremity trauma [3].

Most of the orthopaedic research involving SDOH and health disparities focuses on access to care and outcomes data rather than examining injury patterns. In this issue of Clinical Orthopaedics and Related Research®, Breslin et al. [4] sought to describe a relationship between underlying SDOHs and traumatic musculoskeletal injury. Their institution, Case Western Reserve University, is home to Trauma Recovery Services, a psychosocial support program for patients admitted with traumatic injuries. Trauma Recovery Services offers professional coaching, peer mentorship, post-traumatic stress disorder screening and treatment, and more. In 2019, they implemented a social determinants screening tool for all patients. During the study timeframe, more than 6000 individuals were admitted for traumatic injuries and contacted by Trauma Recovery Services. Among a small subset who completed the screening tool and sustained a musculoskeletal injury, the authors found that Black race, Hispanic ethnicity, and food insecurity were independently associated with intentional mechanisms of injury (such as physical or sexual assault, gunshot wound, or stabbing).

This paper adds to the body of work surrounding SDOH and health disparities in orthopaedic patients. The findings are upsetting, and the study should inspire orthopaedic surgeons to learn more about the intertwining of SDOH, injury patterns, and outcomes.

Where Do We Need To Go?

Orthopaedic surgeons are witnesses to the downstream effects of SDOH. It is necessary to become proficient in public health—to the degree we can—to interpret the available evidence, guide our practices, and contribute to the SDOH body of research in a meaningful way. It is becoming more common for physicians to receive training on SDOH during medical school. The dual MD-MPH degree is also increasingly common, perhaps reflecting interest in and better understanding of population health among physicians [13]. The next big question is how to effectively transform SDOH research findings into advocacy.

Many SDOHs are deeply rooted and far upstream of our clinical interactions with patients. The essential role of the physician is to provide healthcare for patients and families, not necessarily to care for communities. When we are busy meeting our patients’ immediate needs, we may not be well positioned to leverage population health interventions or engage in advocacy work. However, physicians have a detailed understanding of health outcomes as well as public trust and credibility that may uniquely position us to serve as advocates for public health. There has been lively debate on the topic of advocacy and the practice of medicine [8, 10]. Is physician advocacy a professional obligation? A laudable—but optional—activity? A distraction? Given our commitment to our patients and the growing understanding of SDOH, physicians must find ways to complement traditional clinical skills with population-based approaches to practice and advocacy.

Physician advocacy happens on two levels: working in the system on behalf of specific patients (agency) and working to change the system toward equity and improved population health (activism) [6]. Agency is woven into the daily fabric of any healthcare provider. For the busy clinician, finding time and energy for activism is a different matter. Nevertheless, for some involved in trauma care, activism is an antidote to burnout that develops in response to patching up patients only to send them back into the conditions that contributed to their injuries. The burden of building a healthy society does not fall squarely on the shoulders of the treating physician. Physician engagement cannot be allowed to diffuse or absolve government and public health agencies of their important responsibilities, but neither can we extricate healthcare from population health. Our response should be to strengthen partnerships rather than to continue to work in our silos.

How Do We Get There?

An encouraging aspect of this month’s paper by Breslin et al. [4] is their description of the work done by Trauma Recovery Services to identify and meet SDOH needs. Several other institutions have implemented similar programs. For example, Rutgers University is home to the Center for Trauma Survivorship, which conducts needs assessments, screens for post-traumatic stress disorder and depression, provides health navigators, and coordinates behavioral healthcare [11]. Boston University Medical Center founded its Socially Responsible Surgery program in 2014 on the belief that social responsibility is a core value of surgical practice. They have formed a research program, instituted service learning projects for medical students, and partnered with local agencies in advocacy work.

Trauma, pediatrics, and other subspecialties can think creatively about building community partnership, perhaps based on models of community engagement from our sports colleagues who partner with local teams. Opportunities for engagement are numerous. The first step is simply to learn more about health equity and SDOH by reading journal articles and essays across disciplines. Beyond that, physicians could develop a practice culture that values health equity, discuss SDOH at meetings, identify unmet social needs in patients and develop programs and referral networks to help meet them, become a school board advisor or community media liaison, partner with other departments to build transdisciplinary trauma teams, and petition employers and accrediting bodies to recognize advocacy work. The American Hospital Association recently published a toolkit to help hospitals target SDOH in their communities [1]. These suggestions may seem hopelessly broad, but there are examples of physicians who have found ways to engage. For example, Dr. R. noticed multiple childhood injuries in her emergency department related to falls from high-rise windows. She sought a grant to place window guards on large apartment buildings in her community, and documented the subsequent decreased rate of these injuries. This initial effort later led to laws requiring protective guards on all high-rise windows [7].

Finally, we need to measure the successes of our interventions. This may look like the percentage of patients screened for SDOH, the percentage of patients with a positive screen being referred to community-based resources, or the percentage of patients who attend follow-up appointments in trauma clinic.

In a commencement address several years ago, professor and novelist George Saunders urged graduates to err in the direction of kindness, wryly admitting that “kindness, as it turns out, is hard—it starts out all rainbows and puppy dogs, and expands to include...well, everything [12].” This is also the difficulty with SDOH research and programming. It can be easy to lose focus or feel overwhelmed when we’re up against no less than the structure of society and conditions of living. But if we flip that perspective on its head, we see that if the problems are innumerable, then the solutions are as well.