CORR Insights®: High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA

Where Are We Now?

The core goals of value-based care continue to be: to enhance outcomes and quality, improve efficiency, improve value, and improve patient experience. Socioeconomic and medical risk stratification have remained major concerns within this value-based care milieu [1]. Patients with lower levels of educational attainment and fewer financial resources are less likely to be able to access care and more likely to have complications.

Despite the overall success of the procedure, a subset of patients are dissatisfied with their TKA because of persistent pain and stiffness, and this is also reflected in decreased improvement as measured by patient-reported outcome measures (PROMs), which has prompted considerable interest in identifying factors contributing to the variability in postoperative results. PROMs have become integral in evaluating TKA effectiveness, encompassing domains such as pain, physical function, and overall satisfaction. The influence of social, educational, and financial factors on healthcare outcomes has garnered increasing attention, underscoring that social determinants impact health-related quality of life and treatment outcomes. Furthermore, specific racial and ethnic groups are less likely to undergo elective or discretionary surgeries such as TKA [2].

The Area Deprivation Index (ADI) serves as a surrogate measure of socioeconomic status, aggregating neighborhood-level data on income, education, housing, and employment to assess relative disadvantage. Although prior research has linked the ADI with adverse outcomes after TKA, including increased readmission rates and longer hospital stays, its association with PROMs remains less explored [5]. Understanding the interplay between socioeconomic factors and PROMs after TKA is crucial for elucidating disparities in patient-reported experiences and guiding targeted interventions to improve outcomes [6].

Published in this issue of Clinical Orthopaedic and Related Research®, Hadad et al. [4] studied a relatively large retrospective cohort of patients who underwent TKA within a tertiary health system in two states. The authors found that increased socioeconomic disadvantage as determined by the ADI was associated with not achieving the patient-acceptable symptom state (PASS) thresholds for the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and KOOS JR. Interestingly, other PROMs and satisfaction were not associated ADI in the studied patient population. The authors noted that certain socioeconomic factors, as measured by the ADI, may play a confounding role in a patient’s perception of outcome after TKA. Given that the outcomes of our patients are more likely to play an important role in value-based care, further investigation into the relationship between socioeconomic disparities and TKA are warranted. For example, if social, educational, or financial factors influence our ability to measure patient outcomes like pain and functional improvement, we are then required to develop alternative measurements more applicable to all patient populations. If our current measurement tools are less accurate or applicable to some populations, surgeons may choose to defer care in these populations.

Where Do We Need To Go?

Future studies should further differentiate the contribution of specific underlying measurement categories within a tool like the ADI. The ADI incorporates many criteria for scoring, and some of these factors may be more easily identifiable and susceptible to intervention. For example, the ADI is a broad framework, and perhaps elements like employment status and housing status are more important than education. Rather than using a large brush for developing an intervention, a fine pencil might be required.

Although the work of Hadad et al. [4] represents an important step in the journey to better understanding the many factors that affect our patients and procedures like TKA, there is much more to do. Since as many as 20% of our patients who undergo TKA aren’t satisfied with the outcome, further research into the impact of the factors under our control and those outside of our control is needed. Otherwise, outcome thresholds are arbitrary and less likely to improve the outcomes of our patients or the technical aspects of the procedures we perform.

Longitudinal studies that incorporate diverse patient populations and assess a broader spectrum of PROMs could offer deeper insights into the complex interplay between socioeconomic status and postoperative outcomes. Furthermore, research efforts should extend beyond mere association to explore causality, investigating how social determinants influence patient-reported experiences over time. Identifying modifiable socioeconomic risk factors and developing targeted interventions tailored to the needs of patients from disadvantaged backgrounds represent critical steps in mitigating disparities and improving outcomes in TKA recipients.

We need to better understand the differences between racial and ethnic differences that result in variations of care and outcomes. Importantly, our research into the disparities of care must unpack all factors that create both disparities in access and outcome. Ultimately, we want a comprehensive predictive model that incorporates medical, behavioral, psychological, and socioeconomic variables to help us guide our patients through the knee osteoarthritis and knee arthroplasty process.

When we are able to use data to better understand improvement after TKA in all patient populations, researchers and surgeons can better test and implement solutions that may uniformly lead to good and excellent results. Our current research models are not sophisticated, and many of our research initiatives are isolated and random shots in the dark. The impact of socioeconomic factors, as measured through measures like the ADI, hold incredibly greater value when they can be viewed with greater overall variable stratification.

How Do We Get There?

Advancing comprehension within this specialized field necessitates embracing interdisciplinary methodologies and drawing upon insights from diverse disciplines, including orthopaedic surgery, public health, and social sciences. Embracing longitudinal research frameworks becomes imperative to grasp the ever-evolving socioeconomic dynamics influencing postoperative outcomes, enabling a thorough evaluation of patient-reported experiences across time spans. Additionally, integrating qualitative methodologies, such as conducting patient interviews and organizing focus groups, stands to furnish invaluable perspectives into the lived realities of individuals hailing from varied socioeconomic strata. Greater granularity and understanding of the impact of education, economic disadvantage, employment, and supporting social networks on access and improvement after TKA are needed.

Fostering collaboration among researchers, healthcare providers, and policymakers is pivotal in translating research insights into actionable measures geared toward mitigating social determinants of health and ameliorating disparities in orthopaedic care delivery. Implementing multifaceted interventions, spanning from community outreach initiatives to facilitating access to social support services and educational campaigns, holds promise in dismantling the socioeconomic barriers impeding TKA outcomes. By centering equity and inclusivity in both research endeavors and clinical practice, we chart a course toward a healthcare landscape that guarantees equitable access to superior care, thereby elevating outcomes for all TKA patients.

Realizing these ambitions poses formidable challenges, necessitating a substantial influx of research funding. The complexities and nuances surrounding socioeconomic variables, as underscored by the ADI, emphasize the imperative for concerted efforts among musculoskeletal, behavioral, social science, and economic researchers to delineate a cogent framework for advancing this domain. Interdisciplinary collaboration lies at the heart of any endeavor aimed at formulating and implementing a more robust and actionable model for researching, documenting, and ultimately enhancing patient outcomes.

Read This Next

• This article succinctly describes the importance, validity, and applicability of the ADI in evaluating health equity [8].

• Although generally intended to be oriented toward pediatric orthopaedic practice, this review article is excellent at breaking down the concepts within health equity in orthopaedic practice [7].

• This article reviews the essential tenets of patient-reported outcomes and identifies next steps in progressing utilization [3].