What NON-Medical Factors Affect TKA Outcomes?

A team of researchers from Henry Ford Hospital in Detroit, Michigan have published a new study which sets out social determinants of health—defined as the non-medical factors that influence health outcomes. These are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.[1]

The authors collected data from 19,321 total knee arthroplasty (TKA) patients. They found that socioeconomic status, housing type, and transportation access were the most predictive of emergency department visits, readmissions, and complications following total knee arthroplasty.

According to co-author Craig D. Silverton, D.O., vice chairman of the Department of Orthopedics at Henry Ford Hospital in Detroit, Michigan, “By practicing in a large academic hospital system within metro Detroit, we have the opportunity to help a wide array of patients from all backgrounds.”

“As social determinants of health have come into the spotlight recently in orthopedics, we could not help but acknowledge how these factors affect our immediate populace. So, we sought to better understand social determinants of health objectively by associating well-studied neighborhood deprivation indices to outcomes following TKA.”

OTW asked Dr. Silverton to explain why he and the research team selected TKA patients for their study. He said, “TKA is a broadly performed procedure that allowed the study of surgical outcomes in relation to neighborhood deprivation. Furthermore, TKA is unique from total hip arthroplasty in that we still do not understand why 20% of patients have sub-optimal outcomes. While some evidence points towards technical aspects of the surgery, we hypothesized that at least a portion of the 20% could be explained by poor optimization of patients from the most deprived neighborhoods.”

Money and Housing Stand Out

“Based on the results of our investigation, it was clear that the composite Social Vulnerability Index and Area Deprivation Index were the most predictive of emergency department visits, readmissions, and complications following TKA.”

“Of the studied Social Vulnerability Index subthemes, socioeconomic status and housing type/transportation access were the most important. These findings may comment on particular patients not having adequate access to postoperative care and patient education.”

“Our most important results certainly were that across most Social Vulnerability Index sub themes, Social Vulnerability Index, and Area Deprivation Index ranks, greater deprivation associated with greater emergency department visits. Certainly, this would suggest greater costs of care for these patients, highlighting the importance of further investigating optimization options as well as policy changes to better treat TKA patients.”

As for how to operationalize these findings, Dr. Silverton explained to OTW, “These variables should be readily integrated into the preoperative phase of care. Automatic extrapolation of these variables using patient addresses at intake can help identify potential at-risk patients, allowing for early discussion with patients and prompt intervention should a pertinent problem be noted. The steps after identification, however, remains the challenge.”

Societal Issue, Societal Solutions

“Definitely, it is important to provide access to a social worker and information regarding neighborhood resources, but our study highlights societal issues that need policy level changes. Some success has been demonstrated outside of orthopedics in incentivizing practitioners for reducing disparate care outcomes, but implementation of such policies can be challenging.”

And in the end, physicians are supposed to be patient advocates.

“The next steps,” said Dr. Silverton to OTW, “will be to study how automated collection of these variables affect clinical practice prior to TKA or THA. Most importantly, we need to devise a strategy of optimizing patients with known social risk factors. While a part of our work is in the clinical setting, for true societal change, we must do our part on the health policy and advocacy front.”

[1] https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1