Impoverished Communities Underserved by Orthopedics

As with other measures of success in life, where you live plays a role in your health. Evidence from a new study conducted by Hospital for Special Surgery (HSS) and Weill Cornell Medicine, both in New York City, has found that community determines whether someone is discharged to a facility or home. The research (“Community Deprivation Index and Discharge Destination after Elective Hip Replacement”) was published in the January 21, 2020 edition of Arthritis Care and Research.

Using data from nearly 85,000 patients in the Pennsylvania Health Care Cost Containment Council database who had elective hip replacement surgery between 2012 and 2016, the team found that hip replacement patients who lived in the least affluent communities were more likely to be discharged to an inpatient rehabilitation or skilled nursing facility rather than home care.

Bella Mehta, M.B.B.S., M.S., a rheumatologist at HSS, explained the rationale behind the study: “With the aging of the population, elective total hip replacement has become one of the fastest-growing procedures to manage severe osteoarthritis. By 2030, the number of hip replacements is expected to reach 572,000 annually in the U.S. Medicare, the largest payer of joint replacement surgery, has introduced several payment reform models that target discharge destination and risk of hospital readmission after surgery. Our study examined how the socioeconomic status of the community in which one resides influences discharge destination and the odds of 90-day hospital readmission after hip replacement.”

According to the press release, “The researchers used the Area Deprivation Index (ADI) from the American Census Survey, which reflects a geographic area’s level of socioeconomic deprivation and is associated with health outcomes.”

The researchers found that “the interaction effect of race and ADI on discharge destination was statistically significant in African American patients 65 years and older, but not in patients under 65 years old. The level of community deprivation did not have an effect on 90-day hospital readmission, nor did the interaction of ADI and race.”

As a possible explanation for the study findings, Dr. Mehta hypothesized “that patients from impoverished communities may have less access to community-based services such as social support. Thus, discharge to a facility for post-operative and rehabilitative care might be perceived as a safer option in clinical decision-making.”

“Our study is important because it advances our understanding of the relationship between health care and social determinants of health,” stated Said Ibrahim, M.D., M.P.H., M.B.A., senior investigator and chief of the Division of Healthcare Delivery Science and Innovation at Weill Cornell Medicine. “Future studies should determine which specific community factors influence discharge destination and how they could be modified to allow more patients to go home after a hip replacement.”

Asked about any thoughts on which specific community factors influence discharge destination and how they could be modified to allow more patients to go home after a hip replacement, Dr. Mehta told OTW: “Community level factors such as SES [socioeconomic status] may influence the decision for discharge destination are multifactorial. These include patient preferences, family support (impoverished are known to have lesser family support), the health care system/physician preferences, community resources available (for example, accessible streets, sidewalks, walkways, elevators, primary-care physicians [PCPs], urgent care centers), all of which may factor into the decision to discharge to an institution vs home or even 90-day readmissions.”

“Community-level factors play a huge role in health care delivery and access, especially in deprived communities. For patients from low SES communities, institutional post-operative and rehabilitative care might present as a ‘safer’ option in clinical decision-making. Improving access and awareness of hip replacements is the key to allow more patients to go home.”