Abstract
Objectives:
A growing area of interest in orthopaedic surgery is the relationship between social determinants of health (SDOH) and post-operative outcomes. Past population health investigations support that neighborhood-level disparities may portend average life expectancies that differ by 20 to 30 years in adjacent communities, leading health equity researchers to suggest that a patient’s ZIP code may matter more than their genetic code. In efforts to better quantify a patient’s health risk and optimize post-operative recovery, past literature has encouraged the use of the Area Deprivation Index (ADI), a validated tool that calculates neighborhood-level socioeconomic disadvantage. As such, the ADI may help identify neighborhoods that lack resources (e.g. medical services, recreational facilities, or grocery stores) that play a key role in improving overall health and post-operative recovery. This deeper understanding can inspire equitable clinical guidelines along with health policies that mitigate the disparities that disadvantaged patients face. The purpose of the present study was to investigate the effects of neighborhood-level socioeconomic disadvantage on healthcare accessibility and long-term functional outcomes for patients undergoing hip arthroscopy.
Methods:
This retrospective study queried patients with minimum 8-year follow-up who underwent hip arthroscopy for the treatment of symptomatic labral tears secondary to FAI. Included patients were ≥18 years old, underwent primary hip arthroscopy for symptomatic labral tears, had complete patient-reported outcome measures (PROMs) at minimum 8-year follow-up, and resided in the United States. The ADI scores of all included patients were normalized to a relative mean percentile of 50%, and the study population was stratified into quartiles: (Q1) 1-25th, (Q2) 26-50th, (Q3) 51-75th, and (Q4) 75-100th percentiles. Patients in Q1 and Q4 represented the ADILow (least disadvantaged) and ADIHigh (most disadvantaged) cohorts, respectively. Patients in Q2 and Q3 were excluded from further analyses. The primary outcomes were the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score (HOS)–Activities of Daily Living (HOS-ADL), HOS–Sports Specific subscale (HOS-SSS), and 33-item International Hip Outcome Tool (iHOT-33). Secondary outcomes included long-term survivorship measured by conversion to total hip arthroplasty (THA), revision hip arthroscopy, pain levels, rates of achieving the patient acceptable symptom state (PASS) for PROMs, and patient satisfaction.
Results:
There was a total of 43 patients in both the ADILow and ADIHigh cohorts. The only difference in baseline demographics between ADI cohorts was patient sex, with fewer females in the ADILow group (41.9% vs 67.4% female; P=0.017) (Table 1). ADIHigh patients experienced significantly worse healthcare accessibility (Table 2). When comparing minimum 8-year post-operative PROM scores, ADILow patients reported significantly higher scores for all PROMs except for HOS-SSS (77.9±24.7 vs 72.6±28.9; P=0.371). Both cohorts underwent similarly low rates of revision hip arthroscopy rate (ADIHigh: 3 [7.0%] vs. ADILow: 2 [3.7%]; P=0.645). Despite ADIHigh having significantly worse PROMs, both cohorts converted to THA at a statistically similar rate (ADIHigh: 5 [11.6%] vs. ADILow: 9 [20.9%]; P=0.243). By logistic regression, ADIHigh patients had a significantly reduced odds of achieving PASS for mHHS (ADIHigh vs. ADILow, OR: 0.09; 95% CI, 0.01-0.51; P=0.007) and HOS-ADL (ADIHigh vs. ADILow, OR: 0.10; 95% CI, 0.01-0.66; P=0.018) (Table 4).
Conclusions:
In the present study, ADIHigh patients were nearly 11.4 and 10.4 times less likely to achieve 10-year PASS for mHHS and HOS-ADL, respectively. A significantly greater proportion of ADIHigh patients resided in rural communities, primary care HPSAs, MUA/Ps, and counties with a greater rural population. At a patient level, the ADIHigh cohort had lower levels of insurance coverage, education, and household income. This investigation established that hip arthroscopy patients from neighborhoods with greater socioeconomic disadvantage experience worse healthcare accessibility and inferior long-term functional outcomes. While it is important that orthopaedic surgeons understand the consequential effects of SDOH on long-term musculoskeletal health, these findings have far greater implications. Orthopaedic surgeons nationwide must collaborate with patients, hospital systems, and local/state governments to reform healthcare policies that have contributed to these disparities.
