PMID- 36201422 OWN - NLM STAT- MEDLINE DCOM- 20230425 LR - 20240502 IS - 1528-1132 (Electronic) IS - 0009-921X (Print) IS - 0009-921X (Linking) VI - 481 IP - 5 DP - 2023 May 1 TI - Are Detailed, Patient-level Social Determinant of Health Factors Associated With Physical Function and Mental Health at Presentation Among New Patients With Orthopaedic Conditions? PG - 912-921 LID - 10.1097/CORR.0000000000002446 [doi] AB - BACKGROUND: It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery. QUESTIONS/PURPOSES: (1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation? METHODS: New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 +/- 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values < 0.05 designated statistical significance. The concept of minimum clinically important difference (MCID) was used to assess clinical importance. Regression coefficients represent the projected change in PROMIS physical or mental health symptom scores (that is, the dependent variable in our regression analyses) accounting for the other included variables. Thus, a regression coefficient for a given variable at or above a known MCID value suggests a clinical difference between those patients with and without the presence of that given characteristic. In this manuscript, regression coefficients at or above 4.2 (or at and below -4.2) for PROMIS Global Physical Health and at or above 5.1 (or at and below -5.1) for PROMIS Global Mental Health were considered clinically relevant. RESULTS: Among the included patients, 8% (685 of 9057) were unemployed but seeking work, 4% (399 of 9057) reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, 4% (328 of 9057) reported trouble paying for medications, and 2% (181 of 9057) had no current housing. Lack of reliable transportation to attend doctor visits or pick up medications (beta = -4.52 [95% CI -5.45 to -3.59]; p < 0.001), trouble paying for medications (beta = -4.55 [95% CI -5.55 to -3.54]; p < 0.001), Medicaid insurance (beta = -5.81 [95% CI -6.41 to -5.20]; p < 0.001), and workers compensation insurance (beta = -5.99 [95% CI -7.65 to -4.34]; p < 0.001) were associated with clinically worse function at presentation. Trouble paying for medications (beta = -6.01 [95% CI -7.10 to -4.92]; p < 0.001), Medicaid insurance (beta = -5.35 [95% CI -6.00 to -4.69]; p < 0.001), and workers compensation (beta = -6.07 [95% CI -7.86 to -4.28]; p < 0.001) were associated with clinically worse mental health at presentation. CONCLUSION: Although transportation issues and financial hardship were found to be associated with worse presenting physical function and mental health, Medicaid and workers compensation insurance remained associated with worse presenting physical function and mental health as well even after controlling for these more detailed, patient-level SDoH factors. Because of that, interventions to decrease health disparities should focus on not only sociodemographic variables (for example, insurance type) but also tangible patient-specific SDoH characteristics. For example, this may include giving patients taxi vouchers or ride-sharing credits to attend clinic visits for patients demonstrating such a need, initiating financial assistance programs for necessary medications, and/or identifying and connecting certain patient groups with social support services early on in the care cycle. LEVEL OF EVIDENCE: Level III, prognostic study. CI - Copyright (c) 2022 by the Association of Bone and Joint Surgeons. FAU - Bernstein, David N AU - Bernstein DN AUID- ORCID: 0000-0002-1784-3288 AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. AD - Harvard Combined Orthopaedic Residency Program, Boston, MA, USA. AD - Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands. FAU - Lans, Amanda AU - Lans A AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. AD - Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht University, Utrect, the Netherlands. FAU - Karhade, Aditya V AU - Karhade AV AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. AD - Harvard Combined Orthopaedic Residency Program, Boston, MA, USA. FAU - Heng, Marilyn AU - Heng M AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. FAU - Poolman, Rudolf W AU - Poolman RW AD - Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands. FAU - Schwab, Joseph H AU - Schwab JH AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. FAU - Tobert, Daniel G AU - Tobert DG AUID- ORCID: 0000-0001-6168-0175 AD - Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. LA - eng PT - Journal Article DEP - 20221006 PL - United States TA - Clin Orthop Relat Res JT - Clinical orthopaedics and related research JID - 0075674 SB - IM CIN - Clin Orthop Relat Res. 2022 Dec 21;:. PMID: 36542599 MH - United States MH - Humans MH - Middle Aged MH - Aged MH - Mental Health MH - Social Determinants of Health MH - *Orthopedics MH - Cross-Sectional Studies MH - *Musculoskeletal Diseases/diagnosis/therapy PMC - PMC10097559 COIS- Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research(R) editors and board members are on file with the publication and can be viewed on request. EDAT- 2022/10/07 06:00 MHDA- 2023/04/25 10:19 PMCR- 2024/05/01 CRDT- 2022/10/06 13:33 PHST- 2022/05/30 00:00 [received] PHST- 2022/09/15 00:00 [accepted] PHST- 2023/04/25 10:19 [medline] PHST- 2022/10/07 06:00 [pubmed] PHST- 2022/10/06 13:33 [entrez] PHST- 2024/05/01 00:00 [pmc-release] AID - 00003086-990000000-00933 [pii] AID - CORR-D-22-00686 [pii] AID - 10.1097/CORR.0000000000002446 [doi] PST - ppublish SO - Clin Orthop Relat Res. 2023 May 1;481(5):912-921. doi: 10.1097/CORR.0000000000002446. Epub 2022 Oct 6.