Where Are We Now?
In the current study, Wright and colleagues  performed a cross-sectional evaluation for nearly 5 months in an orthopaedic center, matching Patient-Reported Outcomes Measurement Information System (PROMIS) scores to the Area Deprivation Index (ADI). The ADI is “a composite measure of community-level social deprivation”  and it was used to estimate individual social deprivation. The authors found that patients living in zip codes with the highest levels of social deprivation had worse PROMIS scores compared with patients living in the least-deprived quartile. The authors also determined that subspecialties were distinct in terms of the ADI of patients seen—39% of trauma patients were from the most-deprived quartile whereas only 11% of patients in a sports medicine practice were from the most-deprived quartile . Although the results from the current study are consistent with those of another study on social deprivation and patient-reported outcomes , they remain an important addition to our growing knowledge about the effect of social deprivation on health care by focusing on the orthopaedic implications, as opposed to general health outcomes. It is also meaningful to orthopaedic surgeons, because it shows variability between specialties, which is a novel discovery.
One could argue that our understanding of healthcare disparities in the United States has been refined considerably during the past 20 years. In 1999, Congress requested an Institute of Medicine (IOM) study regarding health disparities, resulting in the 2002 publication of Unequal Treatment: Confronting Racial and Ethnic Disparities in Heath Care . Much of the research in the IOM study (and since its release) has focused on racial and ethnic differences, which persist even within equivalent socioeconomic classes. Importantly, just as race and ethnicity are beyond an individual’s control, so too is social deprivation. Yet, both of these uncontrollable factors can effect health and patient-reported outcomes.
Why is it so important to define the relationship between patient-reported outcomes and social deprivation? Because the US healthcare system contains disincentives to caring for socially deprived patients. For example, lower-income individuals are more likely to be uninsured or to have Medicaid, which provides lower reimbursement than do private insurance and Medicare. Lower-income patients are less likely to adhere to recommended medical treatments . If some groups of patients—such as those with greater social deprivation or those with Medicaid insurance (or less)—have lower scores at baseline, payment models need to adjust for this so these already vulnerable individuals do not have less access to care.
Where Do We Need To Go?
The authors found that greater social deprivation, as measured by the ADI, was independently associated with poorer PROMIS scores, even after controlling for age, race, sex and orthopaedic specialty providing care . A prior orthopaedic study  found worse pain and function after stet in black patients from high-deprivation communities compared with black patients from low-deprivation communities, while similar differences were not seen between white patients . Patient-reported outcomes for different orthopaedic surgeries—from fracture fixation to joint replacement to spinal arthrodesis—should be studied not only according to the social constructs of race and ethnicity, but also by social deprivation. Additionally, the authors of the current study found specialty-specific differences in PROMIS outcomes, and this area also requires further exploration.
The cost of care for socially deprived patients should likewise be further defined. Much of what we think we understand about associations between race or ethnicity and orthopaedic outcomes may be simply wrong, and some of this research may even potentiate the very stereotypes that disparities research seeks to alleviate . I wonder whether a great deal of what we think we know about race may be more properly attributed to social deprivation. Future studies need to do a better job of making these important distinctions. For example, there is evidence that re-admissions rates are higher for patients of minority race and ethnicity . This type of work should be expanded to consider the role of social deprivation and whether these patterns hold. Additionally, Medicaid payer status is associated with increased post-operative in-hospital complications and resource utilization for total joint replacement. There is likely overlap between Medicaid status and social deprivation, and further research is needed in this area .
How Do We Get There?
The first step is to better understand the complexity of the interactions between social deprivation, race, ethnicity, Medicaid status, and other sociodemographic factors. Many of these factors are prone to bias and stigma. Also, as suggested by Wright and colleagues , we need to understand why these groups of patients have lower physical and mental health scores, particularly in relationship to orthopaedic conditions.
Next, as reimbursement is increasingly affected by patient-reported outcomes, we need to build in a social deprivation correction so that surgeons are not further disincentivized to care for these patients. We should also examine the effect of social deprivation on other quality indicators, such as the widely used Press Ganey survey. An otolaryngology study found that white and privately insured patients were more likely to complete Press Ganey ; therefore, the experience of non-white and publicly insured or uninsured patients may not be captured. If socially deprived patients are less likely to complete satisfaction surveys, caring for these patients could be further disincentivized.
After we define these relationships, we must advocate for policy changes to incorporate social risk factors into payment models, especially new models, such as bundled payments. “Safety-net” hospitals that care for vulnerable patients are more likely to be penalized and less likely to receive rewards through the Medicare Comprehensive Care for Joint Replacement Model . To ensure access to orthopaedic care, we must consider how to integrate social risk factors into provider payments. The National Academies of Sciences, Engineering, and Medicine have created a report on potential mechanisms to do this , and Massachusetts implemented a “social determinants of health” model for their Medicaid population in 2016 . Orthopaedic surgeons must help define the effects of social deprivation on orthopaedic care, while ensuring that this research does not create further barriers to care.
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