CORR Insights®: Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

Where Are We Now?

As orthopaedic surgeons, it is our responsibility to understand, assess, and document the outcomes of the care we provide to our patients. In that context, it is equally important for us to understand the factors that are predictive of outcomes from the most successful to the least successful. We know about many of these, including age, gender, injury severity, underlying etiology, previous surgery, medical comorbidities, and many other orthopaedic and medical-related factors. Social habits like smoking, drug use, and alcohol consumption likewise are commonly understood to be problematic in this context. Although the role of social determinants of health (SDoH) have become an increasingly important focus in healthcare in a broad sense, only recently have they been recognized for their potential impact on the results of the operations we perform. Orthopaedic surgeons are in the early stages of appreciating the “social, physical, and economic conditions that impact health”, which is the definition of SDoH by the World Health Organization [4], and we’re just coming to understand the importance of each of the five domains of SDoH: economic stability, education access and quality, healthcare access and quality, neighborhood and built environments, as well as social and community context.

The study by Bernstein et al. [1], published in this issue of Clinical Orthopaedics and Related Research®, should be considered a primer for orthopaedic surgeons on geography-based SDoH. Although the study’s primary goals were to correlate the specific geography-based SDoH with each other and then with the PROMIS-10 physical and mental health scores (both of which it definitely accomplishes), more importantly, it provides each reader with a basic understanding of the important geography-based SDoH, how they were developed, and their pivotal role in patient health, access to care, symptom severity, and clinical outcomes. After reading and reviewing this study, my understanding of several key parameters increased exponentially: the Neighborhood Stress Score (NSS) and the seven variables used to define it, the Area Deprivation Index (ADI) and its 17 variables, as well as the Social Vulnerability Index (SVI) and its 16 variables. This study should be required reading for all orthopaedic surgeons and especially for those of us who report on the outcomes of the care we provide.

Where Do We Want To Go?

An increasing number of orthopaedic studies are utilizing the PROMIS-10 physical and mental health scores to assess treatment outcomes. The study by Bernstein et al. [1] shows us that the ADI has the largest association with presenting physical and mental health compared with the NSS and SVI. Going forward, studies that use the PROMIS-10 should also incorporate the ADI (and possibly the NSS and SVI to confirm the findings) in their analyses to truly understand the factors that impact outcomes.

However, there is a larger issue to address. I visited the websites of CORR, the Journal of Bone and Joint Surgery, and the Journal of Arthroplasty where I searched “social determinants of health” to determine how many articles could be identified. Not surprisingly, there were very few, and of those that were identified, as expected, all were published recently. SDoH are only now gaining the attention they deserve in the orthopaedic evidence. Fortunately, the ability to utilize the ADI, SVI, and NSS is based upon knowing the patient’s address (that is, ZIP Code) and correlating it with available national and/or state data, making it relatively easy to incorporate into our outcome studies. As an academic orthopaedic surgeon, I certainly own this issue myself. In the many outcome studies I have published related to the outcomes of shoulder arthroplasty, hip fractures, as well as hip and knee arthroplasty, none have included an analysis of SDoH. Shame on me! It is now time to change this.

How Do We Get There?

Fully incorporating SDoH into orthopaedic surgery will require a multipronged approach. First, we need to educate ourselves about this important area of healthcare. This can occur at the general and specialty meetings we attend through instructional course lectures and symposia. And, of course, each of us can—and should—read up on this essential topic. Second, our journals should publish review articles that provide the necessary background information to understand the definitions of SDoH, their origins, and their impact on the patients we treat. These should include general articles on SDoH in our main journals and subspecialty-specific articles in our specialty journals to gain the widest exposure possible. Third, just as abstracts submitted to peer-reviewed meetings and manuscripts submitted to journals have specific requirements to be considered for presentation or publication (such as minimum 2-year follow-up for reconstructive procedures), requirements for inclusion of SDoH in the analysis of outcomes should be considered. This would send a clear message to our ranks about their importance. And fourth, the ACGME should consider making education about SDoH a requirement in orthopaedic residency training. This approach can be expanded to include ACGME-approved fellowship programs. Including SDoH in our training programs may be the most effective measure because it initiates education at the earliest level. This would be especially timely considering that learning about SDoH now is a part of population health education in our medical schools (NYU Grossman School of Medicine, personal email, November 12, 2023).

I recognize that incorporating SDoH into the mainstream of orthopaedic care and research will be an evolutionary process. Our goal should be to make this timeline as short as possible.

Read This Next

To expand our knowledge of the SDoH and their potential impact on the orthopaedic surgery we perform, I suggest the following references:

• The US Department of Health and Human Services provides in-depth information of the SDoH as part of their “Healthy People 2030” program [3].

• A systematic review concludes that the impediments created by SDoH lead to worse clinical and patient-reported outcomes after rotator cuff repair including an increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work [2].

• Another systematic review finds that certain SDoH, including Black race, Hispanic ethnicity, public health insurance, and lower socioeconomic status, contribute to delays in access to care, which may result in increased severity of concomitant knee injuries encountered at the time of ACL reconstruction and inferior outcomes [5].