What is the Impact of Social Deprivation on Physical and Mental Health in Orthopaedic Patients?
Authors: Wright Melissa A. , Adelani Muyibat , Dy Christopher , O'Keefe Regis , Calfee Ryan P. 
Published: May 2019

Abstract

Background
The complex interrelationship among physical health, mental health, and social health has gained the attention of the medical community in recent years. Poor social health, also called social deprivation, has been linked to more disease and a more-negative impact from disease across a wide variety of health conditions. However, it remains unknown how social deprivation is related to physical and mental health in patients presenting for orthopaedic care.

Questions/purposes
(1) Do patients living in zip codes with higher social deprivation report lower levels of physical function and higher levels of pain interference, depression, and anxiety as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) at initial presentation to an orthopaedic provider than those from less deprived areas; and if so, is this relationship independent of other potentially confounding factors such as age, sex, and race? (2) Does the relationship between the level of social deprivation of a patient’s community and that patient’s physical function, pain interference, depression, and anxiety, as measured by PROMIS remain consistent across all orthopaedic subspecialties? (3) Are there differences in the proportion of individuals from areas of high and low levels of social deprivation seen by the various orthopaedic subspecialties at one large, tertiary orthopaedic referral center?

Methods
This cross-sectional evaluation analyzed 7500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index, a composite measure of community-level social deprivation, based on multiple census metrics such as income, education level, and housing type for a given nine-digit zip code was used to estimate individual social deprivation. Statistical analysis determined the effect of disparate area deprivation (based on most- and least-deprived national quartiles) for the entire sample as well as for patients categorized by the orthopaedic subspecialty providing care. Comparisons of PROMIS scores among these groups were based on an MCID of 5 points for each PROMIS domain (Effect size 0.5).

Results
Patients living in zip codes with the highest levels of social deprivation had worse mean scores across all four PROMIS domains when compared with those living in the least-deprived quartile (physical function 38 +/- 9 versus 43 +/- 9, mean difference 4, 95% CI, 3.7–5.0; p < 0.001; pain interference 64 +/- 8 versus 60+/-8, mean difference -4, 95% CI, -4.8 to -3.7; p < 0.001; depression 50+/-11 versus 45+/-8, mean difference -5, 95% CI, -6.0 to -4.5; p < 0.001; anxiety 56+/-11 versus 50 +/-10, mean difference -6, 95% CI, -6.9 to -5.4; p < 0.001). There were no differences in physical function, pain interference, depression, or anxiety PROMIS scores between patients from the most- and least-deprived quartiles who presented to the subspecialties of spine (physical function, mean 35+/-7 versus 35+/-7; p = 0.872; pain interference, 67+/-7 versus 66+/-7; p = 0.562; depression, 54+/-12 versus 51 +/-10; p = 0.085; and anxiety, 60+/-11 versus 58 +/-9; p = 0.163), oncology (physical function, mean 33+/-9 versus 38 +/-13; p = 0.105; pain interference, 68+/-9 versus 64+/-10; p = 0.144; depression, 51+/-10 versus 52+/-13; p = 0.832; anxiety, 59+/-11 versus 59+/-10 p = 0.947); and trauma (physical function, 35+/-11 versus 32+/-10; p = 0.268; pain interference, 66+/-7 versus 67+/-6; p = 0.566; depression, 52+/-12 versus 53+/-11; p = 0.637; and anxiety, 59+/-12 versus 60+/-9 versus; p = 0.800). The social deprivation-based differences in all PROMIS domains remained for the subspecialties of foot/ankle, where mean differences ranged from 3 to 6 points on the PROMIS domains (p < 0.001 for all four domains), joint reconstruction where mean differences ranged from 4 to 7 points on the PROMIS domains (p < 0.001 for all four domains), sports medicine where mean differences in PROMIS scores ranged from 3 to 5 between quartiles (p < 0.001 for all four domains), and finally upper extremity where mean differences in PROMIS scores between the most- and least-deprived quartiles were five points for each PROMIS domain (p < 0.001 for all four domains). The proportion of individuals from the most- and least-deprived quartiles was distinct when looking across all seven subspecialty categories; only 11% of patients presenting to sports medicine providers and 17% of patients presenting to upper extremity providers were from the most-deprived quartile, while 39% of trauma patients were from the most-deprived quartile (p < 0.001).

Conclusions
Orthopaedic patients must be considered within the context of their social environment because it influences patient-reported physical and mental health as well as has potential implications for treatment and prognosis. Social deprivation may need to be considered when using patient-reported outcomes to judge the value of care delivered between practices or across specialties. Further studies should examine potential interventions to improve the perceived health of patients residing in communities with greater social deprivation and to determine how social health influences ultimate orthopaedic treatment outcomes.

Level of Evidence
Level II, prognostic study.