Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

Abstract

BackgroundTo capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity.Questions/purposesWe asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?MethodsA comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively.ResultsAlthough there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles.ConclusionThese findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJ...

CORR Insights®: Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

“…In their article, Karimi et al [9] highlighted three key aspects of social deprivation as it relates to orthopaedic surgery and the field’s research. Foremost, social deprivation remains an undervalued variable in the perioperative treatment of patients undergoing arthroplasty and those undergoing orthopaedic surgery in general.…”

“…Foremost, social deprivation remains an undervalued variable in the perioperative treatment of patients undergoing arthroplasty and those undergoing orthopaedic surgery in general. Karimi et al [9] demonstrated that few studies examining social deprivation in arthroplasty have been performed; only 19 studies met the inclusion criteria for their review, which spanned a 22-year period. Focusing on social deprivation might improve access to care, increase the use of helpful interventions, and decrease the risk of complications after those interventions.…”

“…In an article in this month's Clinical Orthopaedics and Related Research ® , Karimi et al [9] systematically reviewed articles published from 2000 to 2022 that used indices of social deprivation in patients undergoing primary total joint arthroplasty to determine any correlation between those indices and arthroplasty use, complications, and patient-reported outcomes. Although there was heterogeneity in the analyzed studies, the authors generally noted that indicators of social deprivation are associated with lower arthroplasty use, nonhome discharge, and lower patient-reported symptom improvement from baseline.…”

“…Furthermore, Karimi et al [9] demonstrated that a major obstacle to wider adoption of social deprivation metrics in outcomes research is the lack of a consensus definition. Cheng et al [3] specifically sought to ameliorate this barrier by asking how we should measure social deprivation in patients with orthopaedic conditions.…”

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“…Shared decision-making studies should focus on appropriate patient education regarding expectations, trajectory of functional recovery, and harnessing appropriate resources for social support. My colleagues and I have suggested linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access [1]. Additionally, shared decision-making between patients with social deprivation and their providers or surgeons can improve the health literacy of these patients and subsequently ensure they have adequate access to quality care.…”