Are Social Determinants of Health Disparities Associated With Worse Completion Rates for Patient-reported Outcome Measures After Total Joint Arthroplasty?

BACKGROUND: Patient-reported outcome measures (PROMs) are important markers to assess patient improvement after total joint arthroplasty (TJA). PROMs are increasingly relevant because of new PROM-reporting requirements for elective inpatient TJA from the Centers for Medicare & Medicaid Services. Social determinants of health (SDOH) disparities have been associated with various worse outcomes after TJA, but to our knowledge, it is not yet known how PROM completion may be affected by SDOH disparities.

QUESTIONS/PURPOSES: Among patients undergoing TJA, (1) are there SDOH disparities (such as insurance, transportation access, and living alone) that are associated with differences in PROM completion? (2) Are there neighborhood metrics, including Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI), that are associated with differences in PROM completion?

METHODS: This study was a retrospective, comparative single-institution study of 12,842 patients who underwent primary, unilateral TJA for osteoarthritis between 2019 and 2022. Study participants had a mean ± SD age of 67 ± 10 years, 45% (5745) were men, and 86% (10,131 of 11,833) were White. Mean ± SD national ADI score was 34 ± 21, and SVI score was 0.4 ± 0.3. PROMs were collected within the first year preoperatively and at 6 months, 1 year, and 2 years postoperatively per institutional protocol. Patient demographic and socioeconomic factors were collected from the institutional medical record. We examined whether PROM noncompletion and completion differed in terms of SDOH, including living alone, transportation access, and insurance type. Race and ethnicity were self-reported by patients. We additionally examined whether PROM noncompletion and completion differed in terms of neighborhood metrics including SVI and ADI scores. For proportions, a clinically important difference was defined by a 15% change.

RESULTS: We found no clinically important differences regarding SDOH disparities in terms of PROM noncompletion and completion; specifically, there were no differences in PROM completion based on Black race (preoperative: 13% [312 of 2332] versus 9% [884 of 9501]; p < 0.001; 1 year: 11% [886 of 8015] versus 8% [310 of 3818]; p < 0.001), lack of transportation access (preoperative: 3% [67 of 2002] versus 2% [199 of 8494]; p = 0.01; 1 year: 3% [205 of 7050] versus 2% [61 of 3446]; p = 0.001), living alone (preoperative: 23% [466 of 1988] versus 21% [1750 of 8452]; p = 0.01; 1 year: 23% [1577 of 6999] versus 19% [639 of 3441]; p < 0.001), and commercial insurance preoperatively (62% [1577 of 2563] versus 65% [6675 of 10,279]; p < 0.001). For neighborhood-level metrics, we found no clinically important difference for PROM noncompletion and completion in terms of mean ± SD ADI scores nationally (preoperative: 36 ± 23 versus 34 ± 21; p = 0.004; 1 year: 39 ± 21 versus 33 ± 20; p < 0.001) and SVI scores (preoperative: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.53 to 0.73]; p < 0.001; 1 year: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.61 to 0.80]; p < 0.001).

CONCLUSION: No clinically important difference was found for various SDOH disparities and neighborhood metrics investigated in this study. Considering these findings, lack of transportation access, living alone, race, insurance type, and address-related neighborhood disadvantage may not be strong indicators of PROM completion after TJA. However, SDOH disparities still require further investigation to understand the relationship between other SDOH disparities and different populations outside of our urban institution.

LEVEL OF EVIDENCE: Level III, prognostic study.