Abstract
Objectives:
The impact of social determinants of health (SDOH) on postoperative outcomes in orthopaedic surgery continues to grow. For patients undergoing anterior cruciate ligament (ACL) reconstruction, previous studies have demonstrated that socioeconomic variables are associated with differential patient-reported outcomes and complications. However, delays in care have not been fully explored. Therefore, the purpose of this study was to investigate the association between socioeconomic variables and timing to presentation and surgery in ACLR patients.
Methods:
A retrospective cohort review of patients undergoing ACLR patients at a single healthcare system in a large metropolitan area between January 2020 to December 2023 was conducted. Patients’ demographic variables, mean household income (MHI) and Area of Deprivation Index (ADI) were collected using the electronic medical record and online mapping data tools based on zip codes. Patients with less than 1 year of Patient Reported Outcome Measurment Information System (PROMIS) scores were excluded. The primary outcome was to compare time from injury to orthopaedic presentation and to surgical intervention based on various sociodemographic parameters. The secondary outcome was to compare PROMIS scores at preoperative, 3, 6, and 12 months from surgery based on social determinants of health variables.
Results:
Three-hundred and ninety-eight ACLR patients were included (median age, 21 years; 54.5% male). Compared with White patients, Black patients were more frequently in the lowest median household income (MHI) quartile (54% vs. 9%, respectively; p < .001). White patients were more frequently in the lowest area deprivation index (ADI) quartile when compared with Black patients (50% vs 9%, respectively; p < .001). Black patients experienced a longer delay to surgery compared to White patients, although only approached significance (5.14 vs. 4.14 weeks respectively; p=0.08). Compared to the least deprived ADI quartile 1, those in the highest ADI quartile 4 experienced a significantly longer delay to surgery (5.57 wks. vs 3.0 wks. respectively, p<0.001). Patients in the lowest income quartile experienced significantly longer delay to surgery than patients in MHI quartile 4, (5.14 wks. vs 3.86 wks. respectively; p=0.016). Additionally, increasing age was correlated with longer times from injury to presentation (rs =0.268, p<0.001) and presentation to surgery (rs =0.210, p<0.001). Increasing BMI was correlated with increased time from injury to presentation (rs =0.132, p=0.009). When examining PROs at one year, patients in the lowest income quartile (MHI Q4) demonstrated worse PROMIS-PI (52 vs. 50 p=0.035) and PROMIS-PF (49 vs. 52, p=0.018) scores compared to MHI Q1. Current smokers also demonstrated significantly worse PROMIS-PF scores compared to never smokers (47 vs. 51, p=0.014 respectively)
Conclusions:
Patients in the most socioeconomically deprived and lowest incomes quartiles experience significant delays in presentation and time to ACLR . These socioeconomic differences appear to be associated with worse pain and physical function for these patients at 1 year.
