Social Determinants of Health and Patients With Traumatic Injuries: Is There a Relationship Between Social Health and Orthopaedic Trauma?
Authors: Breslin Mary A. , Bacharach Abigail , Ho Dedi , Kalina Jr Mark , Moon Tyler , Furdock Ryan , Vallier Heather A. 
Published: December 2022

Abstract

Background
Although economic stability, social context, and healthcare access are well-known social determinants of health associated with more challenging recovery after traumatic injury, little is known about how these factors differ by mechanism of injury. Our team sought to use the results of social determinants of health screenings to better understand the population that engaged with psychosocial support services after traumatic musculoskeletal injury and fill a gap in our understanding of patient-reported social health needs.

Question/purpose
What is the relationship between social determinants of health and traumatic musculoskeletal injury?

Methods
Trauma recovery services is a psychosocial support program at our institution that offers patients and their family members resources such as professional coaching, peer mentorship, post-traumatic stress disorder screening and treatment, educational resources, and more. This team engages with any patient admitted to, treated at, and released from our institution. Their primary engagement population is individuals with traumatic injury, although not exclusively. Between January 2019 and October 2021, the trauma recovery services team interacted with 6036 patients. Of those who engaged with this service, we considered only patients who experienced a traumatic musculoskeletal injury and had a completed social determinants of health screening tool. During the stated timeframe, 13% (814 of 6036) of patients engaged with trauma recovery services and had a complete social determinants of health screening tool. Of these, 53% (428 of 814) had no physical injury. A further 26% (99 of 386) were excluded because they did not have traumatic musculoskeletal injuries, leaving 4.8% (287) for analysis in this cross-sectional study. The study population included patients who interacted with trauma recovery services at our institution after a traumatic orthopaedic injury that occurred between January 2019 and October 2021. Social determinants of health risk screening questionnaires were self-administered prospectively using a screening tool developed by our institution based on Centers for Medicare and Medicaid Services social determinants of health screening questions. Mechanisms of injury were separated into intentional (physical assault, sexual assault, gunshot wound, or stabbing) and unintentional (fall, motor vehicle collision, or motorcycle crash). During the study period, 287 adult patients interacted with trauma recovery services after a traumatic musculoskeletal injury and had complete social determinant of health screening; 123 injuries were unintentional and 164 were intentional. Patients were primarily women (55% [159 of 287]), single (73% [209 of 287]), and insured by Medicaid or Medicare (78% [225 of 287]). Mechanism category was determined after a thorough medical record review to verify the appropriate category. An initial exploratory univariate analysis was completed for the primary outcome variable using the Pearson chi-squared test for categorical variables and a two-tailed independent t-test for continuous variables. All demographic variables and social determinants of health with p < 0.20 in the univariate analysis were included in a multivariate binary regression analysis to determine independent associations with injury mechanism. All variables with p < 0.05 in the multivariate analysis were considered statistically significant.

Results
After controlling for potential demographic confounders, younger age (odds ratio [OR] 0.93 [95% confidence interval (CI) 0.90 to 0.96]; p < 0.001), Black race (compared with White race, OR 2.71 [95% CI 1.20 to 6.16]; p = 0.02), Hispanic ethnicity (compared with White race, OR 5.32 [95% CI 1.62 to 17.47]; p = 0.006), and at-risk status for food insecurity (OR 4.27 [95% CI 1.18 to 15.39]; p = 0.03) were independently associated with intentional mechanisms of injury.

Conclusion
There is a relationship between the mechanism of traumatic orthopaedic injury and social determinants of health risks. Specifically, data showed a correlation between food insecurity and intentional injury. Healthcare systems and providers should be cognizant of this, as well as the additional challenges patients may face in their recovery journey because of social needs. Screening for needs is only the first step in addressing patient’s social health needs. Healthcare systems should also allocate resources for personnel and programs that support patients in meeting their social health needs. Future studies should evaluate the impact of such programming in responding to social needs that impact health outcomes and improve health disparities.

Level of Evidence
Level IV, prognostic study.