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. 2024 Jun 26;8:100071. doi: 10.1016/j.jposna.2024.100071

The Impact of Social Deprivation on Health Care Utilization Patterns Following Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures

Elizabeth Cinquegrani 1,⁎, Matthew Van Boxtel 1, Sergey Tarima 2, Jessica Hanley 1
PMCID: PMC12088113  PMID: 40433010

Abstract

Background

Disparities in social determinants of health have been linked to worse patient-reported outcomes, higher postoperative pain, and increased risk of revision surgery following orthopaedic procedures. Identification of perioperative predictors of health care utilization is of particular interest to mitigate cost and improve patient outcomes. The aim of this study is to elucidate the effect of social deprivation levels, using the Area Deprivation Index (ADI), on health care utilization following the pinning of supracondylar humerus (SCH) fractures. Identifying risk factors for discrepancies in health care utilization following SCH fracture fixation can help mitigate unnecessary health care spending and improve the care of vulnerable patient populations.

Methods

This is a retrospective review of a single institution’s experience with SCH fracture pinning between 2010 and 2023. Demographic variables and health care utilization data were recorded within 90 days of surgery. The ADI was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared.

Results

One thousand one hundred eighty-six patients from a single level one trauma center were included in this study. The upper, middle, and lower terciles of ADI consisted of 226, 458, and 502 patients, respectively. The most deprived tercile had greater emergency department (ED) visitation within 90 days of surgery relative to the least and intermediate-deprived terciles (incidence rate ratio [IRR] 1.85, 95% CI 1.10-3.08). Identifying as White was an independent risk factor for increased outpatient clinic utilization (IRR or 1.17, 95% CI 1.03-1.34). Higher levels of social deprivation were independent risk factors for increased ED visitation. There was no difference in 90-day inpatient readmission rates or telephone/telehealth calls made to the clinic between the least, intermediate, and most deprived patients.

Conclusions

This study begins to shed light on how social determinants of health impact the postoperative care of the pediatric orthopaedic patient and which patient populations are the most at-risk for disproportionate resource utilization after pinning of SCH fractures. Understanding these differences may lead to improved patient outcomes while decreasing potentially unnecessary burdens on the health care system.

Key Concepts

  • (1)

    Social determinants of health impact the postoperative care of the pediatric patient in the setting of supracondylar humerus fractures.

  • (2)

    More socially deprived patients are at higher risk of postoperative emergency department visits.

  • (3)

    Patient race is shown to be a factor in postoperative clinic utilization.

Level of Evidence

III, Retrospective Comparative Study

Keywords: Supracondylar humerus, Deprivation, Social determinants of health, Hospital readmission, Closed reduction percutaneous pinning, Pediatric fractures

Introduction

Supracondylar humerus (SCH) fractures are the most common elbow fracture in children, accounting for 3% of all pediatric fractures [1], [2], [3]. The annual incidence of these fractures is estimated at around 177.3 per 100,000 children [3]. SCH fractures most frequently occur in children between the ages of 3 and 7 [1], [4]. Closed reduction and percutaneous pinning (CRPP) is the standard of care for children with displaced SCH fractures [5], [6], [7].

Area Deprivation Index, or ADI, has emerged as an effective measure of a patient’s social determinants of health [8]. The ADI encompasses risk factors beyond a patient’s physical health, such as marginalization, access to resources, and discrimination. The ADI score is based on 17 US census-based factors, including race, income, housing, insurance type, and education [8]. These nonphysical factors may have significant effects on a person’s overall health. ADI has been shown to be a predictor of increased pain, depression, and anxiety following orthopaedic procedures [9], [10], [11]. Increased social deprivation has been associated with worse Patient-Recorded Outcomes Measurement Information System (PROMIS) scores before and after treatment of orthopaedic injuries, even in pediatric patients [12], [13], [14]. There is also an increased risk of orthopaedic injuries and poor compliance in those who are more socially disadvantaged [11], [15], [16].

Health care utilization is relevant to the discussion of ADI because the degree to which individuals can access health care has been found to be affected by the factors used to measure ADI. Previous literature has shown discrepancies in hospital utilization as a function of socioeconomic status, with higher degrees of social deprivation associated with increased inpatient management, leading to an increased financial burden on the health care system [17], [10]. Regarding SCH fractures specifically, the literature supports one postoperative visit to pull pins at 3 to 4 weeks [18]. Literature has found that there is no clinical utility in earlier postoperative visits for uncomplicated SCH fractures, as well as postoperative radiographs and additional follow-up visits [19], [18].

Racial and ethnic disparities have also been shown to be a factor in health care utilization and determining patient outcomes. Non-White patients have been shown to have generally poorer orthopaedic outcomes [11], [14], [17], [20], [21], as well as greater delays in orthopaedic care [11], [22], [23], [24]. Specifically, compared to White patients, minority patients have been shown to be less likely to receive imaging in the emergency department (ED), less likely to be diagnosed with an orthopaedic injury, and less likely to receive outpatient care after sustaining an injury [10], [12], [14], [22].

To our knowledge, there is no literature examining the impact of social deprivation on health care utilization after pediatric SCH CRPP. Health care utilization, in this case, is defined as the postoperative use of medical resources, including (1) inpatient readmission, (2) ED visits, (3) clinic appointments, and (4) telephone/telehealth services. Several studies have shown ADI to be a predictor of health care utilization following various orthopaedic procedures [11], [15], [25], but this literature is currently limited to the pediatric population.

The aim of this study is to elucidate the effect of social deprivation levels on pediatric health care utilization within 90 days of CRPP of SCH fractures. We hypothesize that patients with higher levels of social deprivation will have increased hospital readmission and ED visits as well as poorer postoperative clinic visit compliance and decreased use of telephone/telehealth services compared to pediatric patients experiencing a lesser degree of social deprivation.

Materials and methods

This is a retrospective review of pediatric patients between the ages of 0 and 18 years who underwent CRPP of SCH fractures (Current Procedural Terminology code 24538) between 2010 and 2023. The TriNetX query network, a data exploration tool that is used to obtain deidentified patient data within our institution, was used to access patient information. Patients with open fractures were excluded in an attempt to minimize additional confounders. Patients were also excluded if there was no surgical date in the extracted data. Demographic data, including age, gender, and self-reported race, were collected. Health care utilization data included readmission, ED visits, postoperative orthopaedic office visits, and telephone or telehealth encounters. Data were analyzed if it was recorded within 90 days of the procedure.

ADI scores were calculated for this population based on the patient's address at the time of surgery. The score is a representation of social deprivation in each census block and is public data available through the University of Wisconsin Neighborhood Atlas [8]. ADI values are national percentile rankings from 1 to 100, with higher numbers corresponding to greater relative disadvantage. Patients were stratified into terciles based on their score, with groups 1, 2, and 3 representing the least, intermediate, and most deprived patients, respectively.

IBM SPSS (Armonk, NY: IBM Corp) statistical software was used to perform statistical analysis. Continuous data are presented as means and standard deviations, while categorical data are presented as percentages. Statistical analysis for continuous variables was performed using analysis of variance, and independent sample t-tests where appropriate. Associations between ADI and categorical variables were analyzed using Chi-square tests. Simple and multiple logistic regressions were used to analyze binary health care utilization outcomes (90-day readmissions), while Poisson regression was performed for count data (ED visits, office visits, and telephone calls). The results of logistic regression model fit were used to obtain odds ratios and 95% confidence intervals. The results of Poisson regression model fits were used to obtain IRRs and 95% CIs. A P-value of less than .05 was used to determine significance. No adjustments for multiple comparisons were used in this exploratory study to preserve statistical power.

Results

One thousand one hundred eighty-six patients met the inclusion criteria. Demographic data grouped by tercile are displayed in Table 1. There were 226 patients in the first tercile (least deprived), 458 in the second, and 502 in the third (most deprived). Forty-eight percent (568/1,186) of patients were identified as female, while 52% (618/1,186) were identified as male. In all, 70.7% of patients (838/1,186) identified as White or Caucasian. The most deprived tercile had a significantly higher percentage of patients who were identified as Black or African American (30.3%) compared to the least (1.8%) and intermediate (6.6%) deprived groups (P < .001) (Fig. 1).

Table 1.

Patient demographics and outcomes.

Deprivation group Least Intermediate Most P-value
Number 226 458 502
Age (years) 5.9 ± 3.1 6.3 ± 3.1 5.6 ± 3.2 L vs I: .270M vs I:.003
L vs M: .533
Sex (% male) 42.5 53.3 55.4 L vs I: .008
M vs I: .513
L vs M: .001
Race (%)
White 87.6 80.8 53.8
Black 1.8 6.6 30.3 <.001
Other 10.6 12.7 15.9
Rate of 90-day readmission (%) 2.7 2.4 2.4 L vs I: .841 
M vs I: .991 
L vs M: .832
Rate of ED visits in 90 days (%) 8.0 8.1 13.7 L vs I: .959 
M vs I: .005 
L vs M: .026
Number of follow-up visits in 90 days 1.9 ± 1.5 1.9 ± 1.4 1.8 ± 1.4 L vs I: .966 
M vs I: .104 
L vs M: .347
Number of telephone calls in 90 days 0.3 ± 0.8 0.3 ± 0.9 0.3 ± 0.8 L vs I: .995 
M vs I: .587 
L vs M: .765
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L, least deprived; I, intermediate deprived; M, most deprived.

Pairwise comparisons of P-values for each demographic and outcome variable.

Bold: Values that were significant according to P<0.1.

Figure 1.

Figure 1

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Patient race by tercile. W, White or Caucasian; B, Black or African American; O, Other.

The overall rate of 90-day readmission after surgery was 2.4%. The least, intermediate, and most deprived groups had a 90-day readmission rate of 2.7%, 2.4%, and 2.4%, respectively (Table 1). The level of social deprivation was not associated with increased odds of hospital readmission within 90 days (odds ratio [OR] 0.63, 95% CI 0.21-1.86). No independent predictors for hospital readmission within 90 days of surgery were identified (Fig. 2).

Figure 2.

Figure 2

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Hospital utilization by risk factor. Comprehensive forest plot displaying odds/incidence ratios stratified by predictor of the 4 parameters of hospital utilization: 90-day readmission, ED visitation, office visitation, and telephone calls. Here, patients identifying as Black were the reference group.

The overall rate of 90-day ED visitation after surgery was 10.5%. The average rate of ED visits within 90 days of surgery was 8.0%, 8.1%, and 13.7% for the least, intermediate, and most deprived groups, respectively (Table 1). There were significant differences between groups, with the most deprived group having a higher average number of ED visits than the least (P = .026) and intermediate (P = .005) deprived groups (Table 1). There was no difference in visits between the least and intermediate-deprived groups. There was a 1.85 times greater chance of an ED visit for patients in the most deprived tercile (IRR 1.85, 95% CI 1.10-3.08) when adjusted for age, race, and sex (Fig. 2). Race and sex were not independent predictors for ED visits within 90 days of surgery (Fig. 2).

The average number of office visits within 90 days of surgery was 1.9, 1.9, and 1.8 for the least, intermediate, and most deprived groups, respectively (Table 1). There were no significant differences between terciles (Table 1). Relative to patients who identify as Black, patients who identified as White or Caucasian were an independent predictor for increased utilization of office visits within 90 days of surgery (IRR 1.17, 95% CI 1.03-1.34) (Fig. 2). Sex and social deprivation level were not predictors for increased office visitation (Fig. 2).

On average, less than one phone call or telehealth visit was made per patient within 90 days of surgery across terciles. Therefore, there was no significant difference in the use of telephone/telehealth services between the least, intermediate, and most deprived groups (Table 1). No independent predictors for the number of telephone encounters within 90 days of surgery were identified (Fig. 2).

Discussion

It has been previously established that social determinants of health have an impact on patient outcomes, and increased social deprivation is associated with worse outcomes following orthopaedic procedures [9], [11], [12], [22], [23], [24], [26], [27]. To our knowledge, this is the first study that correlates ADI with the use of health care resources specifically following CRPP of pediatric SCH fractures. Factors influencing the ADI include household income, race, parent/guardian employment and education, and housing characteristics, making the ADI a comprehensive measurement of relative disadvantage.

In this study, we found that more socially deprived patients had significantly increased rates of ED visits within 90 days of CRPP. This increase in health care utilization results in increased costs and burdens on the health care system. These results are in line with what has been previously reported in the literature [12], [25], [28], [29], demonstrating the need for more robust patient intervention to address the discrepancies in health care utilization, even in the pediatric population. Studies have shown that patients experiencing increased social deprivation are more likely to present to the ED than the clinic [30]. This could be due to decreased access to primary care, poor relationships with primary or specialty care providers, or lack of reliable transportation to postoperative office visits. This trend is also consistent with our finding that more socially deprived patients had increased rates of ED visits.

Although identifying as Black was not a risk factor for increased ED and inpatient utilization in this study, it was associated with fewer postoperative office visits compared to White patients. It is beyond the scope of this study to conclude whether the root of this discrepancy is fewer scheduled postoperative visits or an increased no-show rate. A previous study of the pediatric population at our institution demonstrated that identifying as Black was an independent risk factor for missing an orthopaedic follow-up appointment [31], demonstrating that race may be an important factor in a patient’s postoperative course. While identifying as White was found to be a predictor of increased clinic utilization as compared to those identifying as Black, those identifying as White did not present to the clinic more than a typical postoperative course [18].

These results highlight the interplay of ADI and postoperative care in the pediatric orthopaedic patient. ADI has the potential to be an effective screening tool in identifying patients who may be at risk for increased visits to the ED and health care utilization after orthopaedic surgery. Further thought should be given to the idea of including a patient’s ADI score in the medical record, in the same way that other demographic information is recorded. This allows medical professionals to easily identify patients who may need more extensive patient education/counseling, require further aid, or even benefit from social work consultation. Arant et al. discuss that sources of inequality in pediatric orthopaedics can potentially be addressed by removing barriers that often occur in the form of insurance status, transportation, and health literacy [12]. Furthermore, Batley et al. found that patients with a higher ADI receiving pinning of slipped capital femoral epiphysis were lost to follow-up earlier than their less deprived counterparts, suggesting a relationship between higher ADI and the risk of inadequate postoperative monitoring [15]. Disadvantaged pediatric populations may benefit from assistance with caretaker transportation, access to resources, and more detailed education of caregivers about the expected surgical course and appropriate outlets for postoperative care.

There are several limitations to our study. First, we sourced our data from a large database, which relies on the correct entry of diagnosis codes and patient information. Further data regarding the specific type of SCH fracture were not available in the data set, which could possibly skew postoperative data if the severity of fractures significantly differs across terciles. The database also does not provide information regarding patient insurance status, which would be an additional helpful variable in characterizing the patient population. Another intrinsic limitation of the database is the inability to determine specifics surrounding reasons for presentation to the ED and details of scheduled clinic visits. We were also unable to capture any admissions to outside hospitals or patient presentations to outside EDs. We acknowledge that our lack of information regarding fracture severity, hospital admissions, or ED visits are confounding variables. However, our findings may still be valuable in presenting information regarding generalized postoperative trends across socioeconomic groups. Additional studies examining patient charts in further detail could be valuable in providing context to the data set forth in this study.

The ADI has intrinsic limitations in that it relies on census block groups, and a patient’s individual socioeconomic status may not correspond to the average within their census block. The ADI also relies on data from the American Community Survey, which is repeated every 5 years; therefore, it may not represent a patient’s most recent place of residence. The overall aim of the study is to assess generalized trends; thus, the authors feel these findings are still inherently valuable.

Conclusions

A patient’s level of social deprivation may influence the use of health care resources following CRPP of SCH fractures in the pediatric population. Understanding how social deprivation specifically impacts the pediatric surgical patient will help optimize the postoperative experience for both patients and providers as well as minimize unnecessary burden on the health care system.

Additional links

Ethics approval and consent

The author(s) declare that no patient consent was necessary as no images or identifying information are included in the article.

Author contributions

Elizabeth Cinquegrani: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Matthew Van Boxtel: Writing – review & editing, Investigation, Formal analysis. Sergey Tarima: Writing – review & editing, Formal analysis, Conceptualization. Jessica Hanley: Writing – review & editing, Visualization, Supervision.

Declarations of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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