Where does your total knee patient live? Do they have a college degree, access to transportation, adequate housing? Researchers from multiple sites found that these factors DO affect total knee arthroplasty (TKA) outcomes.
The teams collected 10 years of retrospective socioeconomic data covering such factors as education and housing, and tested the prognostic implications of these data for patient outcomes.
Their study, “A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient,” appears in the September 2024 edition of The Journal of Arthroplasty.
According to study co-author Nicolas Piuzzi, M.D., an orthopedic surgeon with Cleveland Clinic in Ohio, “Prior studies indicate that socioeconomic status can heavily influence health disparities, leading to varied postoperative results. Given our commitment to addressing these disparities and improving outcomes for all patient demographics, we designed this nationwide study to analyze how socioeconomic deprivation, as measured by the Area Deprivation Index, affects TKA outcomes across the United States.”
The results of this study, said Piuzzi, support tailored interventions which address socioeconomically disadvantaged patients.
The research teams used the Area Deprivation Index which is a weighted index of 17 census-based markers of material deprivation and poverty. The higher the number, the more the disadvantage. That data was then compared to such outcome data as complications, emergency department utilizations, readmission rates, and 90-day costs.
The results of the study showed a clear pattern. “Patients from high Area Deprivation Index areas showed statistically significant increases in medical complications within 90 days post-TKA, including higher rates of respiratory failures, acute kidney injuries, and urinary tract infections, despite a slight decrease in readmission rates,” said Dr. Piuzzi.
“Emergency department utilization was also notably higher among these patients, indicating that socioeconomically deprived patients may rely more on emergency services post-surgery.”
“Additionally, healthcare costs for patients from high Area Deprivation Index areas were over $2,500 greater than those from lower-risk areas, even when controlling for factors like age and comorbidity burden. These findings highlight the importance of addressing socioeconomic deprivation as a risk factor in clinical outcomes and cost management.”
Interestingly, the team not only looked at patients within higher socioeconomic risk levels, but also patients “near” such neighborhoods. OTW asked Dr. Piuzzi about that: “This approach allows for a broader understanding of the effects of proximal socioeconomic deprivation on patient outcomes, as healthcare access, transportation, and social services in nearby areas may still significantly impact patients’ health and postoperative recovery, even if they do not reside exclusively within those disadvantaged neighborhoods, supporting the idea that proximity to these areas can still capture socioeconomic factors impacting patient outcomes.”
Regarding the choice of 17 census-based markers of material deprivation and poverty, Dr. Piuzzi told OTW, “The 17 markers representing various economic and social indicators included median income, educational attainment, employment levels, housing quality, and access to essential resources. While each marker provides insight into socioeconomic deprivation, factors like income, employment status, and education level are generally understood to influence healthcare access, continuity of care, and overall health outcomes. Although we can’t pinpoint which specific markers are most critical from this study alone, these factors emcompassed by Area Deprivation Index are considered important in predicting post-surgical recovery and may relate to complication risks.”
OTW asked Dr. Piuzzi for his opinion regarding the “lowest hanging fruit” for employing these study results in a care setting. “Case managers could focus on improving access to basic resources and ensuring support for follow-up care post-surgery,” Dr. Piuzzi said.
“Practical interventions such as arranging reliable transportation for follow-up appointments, coordinating home health services, or providing access to affordable post-discharge care can potentially reduce reliance on emergency services for minor issues.”
“Additionally, patient education on managing postoperative symptoms and when to seek emergency department care versus alternative resources may further enhance outcomes and reduce unnecessary healthcare utilization.”
Finally, Puizzi noted; “Future studies could benefit from a deeper dive into specific social determinants that most directly affect post-surgical outcomes and exploring how long-term health outcomes vary among patients in deprived versus non-deprived areas.”
“A longitudinal analysis extending beyond 90 days would allow for insights into chronic complications and health service utilization trends. Additionally, interventions targeting high Area Deprivation Index patients’ specific needs—such as personalized discharge planning, socioeconomically adjusted risk stratification models, and policies that incentivize hospitals to serve higher-risk populations—could further mitigate the disparities identified in this study.”
