CORR Insights®: Are Detailed, Patient-level Social Determinant of Health Factors Associated With Physical Function and Mental Health at Presentation Among New Patients With Orthopaedic Conditions?

Where Are We Now?

Numerous studies in recent years have addressed the associations between social determinants of health and orthopaedic conditions. Some, like the current study [1], have addressed orthopaedic problems in general, while many have focused on specific diagnoses including total joint arthroplasty, ACL reconstruction, meniscus tears, and shoulder injuries [3, 6, 7]. These studies have demonstrated a relationship of social determinants of health with timely access to care and treatment outcomes. The term “social determinants of health” encompasses an extensive list of parameters including occupation, unemployment, education level, minority status, income, place of residence, medical comorbidities, insurance type, tobacco and preoperative narcotic use, housing instability, and access to transportation [2, 3]. These studies have categorized how these factors might intersect with orthopaedic practices to affect (or be associated with) access to care and treatment outcomes. The variety and number of variables make for a confusing way forward, and many of these seem out of reach for remediation in the healthcare setting. But knowing the parameters to be cognizant of will allow us to adjust routines to fit the needs of certain populations and at least help provide better and more convenient treatment options.

The current paper [1] reported specific social determinants of health among patients presenting to a large-city orthopaedic practice and correlated these factors with physical and mental function. The conclusions indicate that decreased physical function was associated with a lack of adequate transportation for clinic visits or medication acquisition, difficulty paying for medications, and workers compensation and Medicaid insurance. Decreased mental health was also associated with difficulty paying for medication, as well as with workers compensation insurance. The magnitude of the problem in the current study seems low, with none of the factors identified occurring in more than 8% of the surveyed population; some were as low as 2%. But the authors point out that even 2% is a very large number of patients if extrapolated across our population. Although specific diagnoses or treatment outcomes were not considered in this study [1], the authors offered strategies to help mitigate the circumstances of concern they identified, such as taxi vouchers or telemedicine for transportation issues and medication assistance programs for financial concerns. For housing instability and employment issues, they suggested establishing proactive outreach programs to connect patients with relevant government services.

Based on the information in this paper, orthopaedic practices should include social information in inpatient records and be prepared to address obstacles the patient may expect to encounter while navigating the healthcare system.

Where Do We Need To Go?

To adequately address access to care and treatment outcomes, it would be helpful to have more information about cause and effect. That is, what is it about education level or low income that causes the failure of a rotator cuff repair or a surgical site infection? Such social determinants do not cause biologic complications. The only likely cause-effect relationship between social factors and biologic consequences might involve care and our inability to communicate effectively. For example, poor communication might affect a patient’s understanding of postoperative precautions or their inability to afford medications or treatment aids. Clarifying this information would provide the basis for practices or institutions to address these issues at a local level.

Because access involves factors that occur before the patient presents to the orthopaedist, assistance in developing outreach programs would be beneficial. Programs that interact with the community and involve the primary care network could create a more welcoming, trusted, and efficient environment to help patients be seen in a timelier fashion.

How Do We Get There?

The first step is to understand there is a dual nature to this problem. One, we need to understand the social and economic realities of our population and work to achieve equity in healthcare in this context. Second, we need to address the underlying causes of inequalities [2].

This study [1] and others [3-6] address the former. They are accumulating the information we need to begin, but more-focused studies that address specific interventions and associated treatment outcomes are necessary. Prospective case-based follow-up studies would be a good start. Also, a mindset change by the orthopaedic community at large and associated healthcare institutions to prioritize the social determinants of health that are addressable at their level is perhaps overdue. This can be done, for example, with prospective follow-up studies by individual practices in which social determinants of health are related to interventions and clinical results. Such specific information is needed if the orthopaedic community and associated healthcare institutions are to find an incentive to prioritize the social determinants of health in their practice routines. Communication with primary care physicians or networks to identify and treat comorbidities before initiating elective orthopaedic procedures will improve access and outcomes. Future studies should focus on interventions to address social inequities and thus provide guidance about which are, or are not, beneficial in creating a more culturally and financially welcoming environment.

Many social determinants of health are larger than local and best addressed by private corporate initiatives, public health programs, or political action [2]. Corporate initiatives described by O’Connor [4] in a recent “Equity360” column offer yet another means for moving forward. By placing patient care services in multiple commercial locations, Walgreens, CVS, and Walmart are delivering primary healthcare to an underserved population. Although perhaps an end run around our public health and political systems, they are addressing inequities those systems have not been able to handle. As pointed out, for the orthopaedic surgeon, corporate initiatives can lead to improved clinical outcomes by reducing comorbidities preoperatively, but traditional referral patterns will likely be disrupted because corporate health plans will likely develop their own referral networks.