The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

The Effect of Greater Area Deprivation and Medicaid Insurance Status on Timing of Care and Rate of Reinjury After Anterior Cruciate Ligament Reconstruction

Background

Lower socioeconomic status and public insurance lead to a longer delay to surgery and a higher likelihood of concomitant pathology before undergoing anterior cruciate ligament reconstruction (ACLR). However, few studies have examined the influence of community deprivation on ACLR timing and outcomes.

Purpose/Hypothesis

The primary aim of this study was to define the effect of the area deprivation index (ADI) and insurance classification on access to orthopaedic care after an ACL rupture, and the secondary aim was to determine whether these variables were associated with a second ACL injury after primary ACLR. It was hypothesized that patients with a greater national ADI percentile and Medicaid insurance would experience longer delays to care and an increased risk of reinjury after ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective study was performed to evaluate patients undergoing primary ACLR between 2016 and 2019. The national ADI percentile was obtained utilizing the Neighborhood Atlas website. The relationship between national ADI percentile and care characteristics (eg, time to specialized care) was investigated using the Spearman rho correlation coefficient (r). The association between patient and care characteristics and second ACL injury after the index procedure (ie, graft rerupture or contralateral ACL rupture) was investigated using binary logistic regression.

Results

A total of 197 patients met the inclusion criteria. Longer times from injury to surgery (r = 0.238; P < .001) and from specialized care to surgery (r = 0.217; P = .002) were associated with a greater national ADI percentile. The second injury group reported significantly greater national ADI (P = .026) and included a greater percentage of patients with Medicaid insurance (31.3%) compared with the no second injury group. Patients experienced 5.1% greater odds of a second ACL injury for each additional month between evaluation and surgery.

Conclusion

Greater national ADI percentile and Medicaid insurance status were associated with adverse ACLR timing and outcomes. Patients with a greater national ADI percentile took significantly longer to obtain surgery after ACL injury. Those who sustained a second ACL injury after ACLR had an overall higher mean national ADI percentile and included a greater proportion of patients with Medicaid compared with those who did not sustain a second ACL injury. Future studies should critically investigate the underlying factors of these associations to reach equity in orthopaedic care.

Surgeon Prioritization of Mental, Social, and Pathophysiological Aspects of Health Among People With Traumatic and Nontraumatic Musculoskeletal Conditions

BACKGROUND

There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models.

METHODS

In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis.

RESULTS

Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology.

CONCLUSION

Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors.

CLINICAL RELEVANCE

Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.

Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics

OBJECTIVES

This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation.

METHODS

A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture).

RESULTS

In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001).

CONCLUSION

Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.

Pediatric Trauma Recidivism: A Statewide Risk Factor Analysis of the Maryland Health Services Cost Review Commission (HSCRC)

BACKGROUND

National estimates suggest pediatric trauma recidivism is uncommon but are limited by short follow up and narrow ascertainment. We aimed to quantify the long-term frequency of trauma recidivism in a statewide pediatric population and identify risk factors for re-injury.

METHODS

The Maryland Health Services Cost Review Commission Dataset was queried for 0-19-year-old patients with emergency department or inpatient encounters for traumatic injuries between 2013 and 2019. We measured trauma recidivism by identifying patients with any subsequent presentation for a new traumatic injury. Univariate and multivariable regressions were used to estimate associations of patient and injury characteristics with any recidivism and inpatient recidivism.

RESULTS

Of 574,472 patients with at least one injury encounter, 29.6% experienced trauma recidivism. Age ≤2 years, public insurance, and self-inflicted injuries were associated with recidivism regardless of index treatment setting. Of those with index emergency department presentations 0.06% represented with an injury requiring inpatient admission; unique risk factors for ED-to-inpatient recidivism were age >10 years (aOR 1.61), cyclist (aOR 1.31) or burn (aOR 1.39) mechanisms, child abuse (aOR 1.27), and assault (aOR 1.43). Among patients with at least one inpatient encounter, 6.3% experienced another inpatient trauma admission, 3.4% of which were fatal. Unique risk factors for inpatient-to-inpatient recidivism were firearm (aOR 2.48) and motor vehicle/transportation (aOR 1.62) mechanisms of injury (all p < 0.05).

CONCLUSIONS

Pediatric trauma recidivism is more common and morbid than previously estimated, and risk factors for repeat injury differ by treatment setting. Demographic and injury characteristics may help develop and target setting-specific interventions.

LEVEL OF EVIDENCE

III (Retrospective Comparative Study).

Statistical groupings of mental and social health measurements correlate with musculoskeletal capability - A cross sectional study

OBJECTIVE

A better understanding of the degree to which social health factors contribute uniquely to statistical clusters associated with variation in levels of capability might inform targeted whole person care strategies for more comprehensive management of musculoskeletal health. Therefore, we asked: (1) What are the statistical groupings of social and mental health measurements in patients seeking specialty care for musculoskeletal conditions? (2) Do identified psychosocial groupings correspond with different mean magnitudes of incapability accounting for demographic and clinical factors?

METHODS

We included 158 patients seeking musculoskeletal specialty care and collected measures of magnitude of incapability, unhelpful thoughts and distress regarding symptoms, symptoms of depression, symptoms of anxiety, and social health. A k-means clustering algorithm was fit to the data and a linear regression model compared mean PROMIS-PF CAT scores for grouping.

RESULTS

A quantitative social health measure contributed to 4 statistical clusters as follows: 1) relatively low levels of all mental health measures and high social health; 2) greater unhelpful thoughts and distress regarding symptoms, average symptoms of general anxiety and depression, and average social health; 3) higher levels of all mental health measures and severely compromised social health; and 4) severely compromised mental health and lower social health. Magnitude of incapability was significantly greater for groups with worse mental and social health.

CONCLUSION

The finding of a relatively independent association of social and mental health factors with greater incapability supports the importance of introducing comprehensive health strategies in musculoskeletal specialty care. Strategies may include mindset training and case management of social unmet needs.

LEVEL OF EVIDENCE

Level III; Cross-sectional study.

Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

BACKGROUND

The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed.

QUESTIONS/PURPOSES

(1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content?

METHODS

Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension.

RESULTS

ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005).

CONCLUSION

Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT.

CLINICAL RELEVANCE

Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Responsiveness of the Brief Michigan Hand Outcomes Questionnaire and Patient-Reported Outcomes Measurement Information System Pain Interference in the Context of Patient Mental Health

PURPOSE

A patient-reported outcomes measure (PROM) is responsive if it is sensitive to clinical status changes. The minimal clinically important difference (MCID) is used to indicate meaningful change, helpful in designing studies and adding context to some study results, and is related to instrument responsiveness. Our purpose was to provide MCID estimates for the brief Michigan Hand Outcomes Questionnaire (bMHQ) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) in a hand and upper extremity surgery cohort within the context of varying patient-reported mental health.

METHODS

Data were analyzed from 1,262 adult patients who received surgical care at a single center between January 1, 2018, and December 31, 2019. Patients completed PROMIS PI, PROMIS Global Health (including global mental health [GMH] component), bMHQ, and a pain-focused anchor question before each clinic visit. Data were collected 8 ± 2 weeks before and after surgery. A distribution-based MCID then was calculated for the general patient population, lowest 10th percentile of GMH scores, and top 10th percentile of GMH scores.

RESULTS

Minimal clinically important difference estimates were 10.4 for the bMHQ and 4.3 for PROMIS PI. Analysis of MCID across different GMH score groups showed a mean score of 11.5 for bMHQ for the lowest 10th percentile of GMH, 9.6 for bMHQ for the top 10th percentile, 4.5 for PI for the lowest 10th percentile, and 4.9 for PI for the top 10th percentile.

CONCLUSIONS

Analysis of subgroups stratified by preoperative patient-reported mental health condition found that preoperative mental health status, as indicated by GMH score, does not have a meaningful impact on responsiveness of bMHQ or PROMIS PI.

CLINICAL RELEVANCE

A patient's reported mental health condition does not meaningfully change how these common PRO instruments reflect the patient condition after hand and upper extremity surgery.

Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients

INTRODUCTION

Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes.

OBJECTIVE

The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level.

METHODS

The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition.

RESULTS

From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01).

CONCLUSION

Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.

The Effect of Social Deprivation on Patient Satisfaction in Otolaryngology Clinics

OBJECTIVES

Multiple factors have been associated with lower satisfaction scores. We hypothesize that patients with a more deprived socioeconomic status will have different patient satisfaction scores than patients of higher socioeconomic status.

METHODS

We reviewed Press Ganey satisfaction scores for new, outpatient visits between January 1, 2014, and December 31, 2018. Due to the high ceiling effects of the survey, "satisfaction" was defined as achieving a perfect score of 100. We determined social deprivation using the 2015 Area Deprivation Index (ADI) which serves as a proxy for socioeconomic status derived from zip codes. Patient satisfaction was defined as a binary variable. Univariate and multivariate binary logistic regression analyses were used to identify factors correlated with patient satisfaction.

RESULTS

There were 3239 unique new patients with completed surveys. Univariate analysis demonstrated decreased odds of achieving satisfaction for both the Total Score and Provider Sub-Score for each decile increase in ADI (OR 0.94; CI = 0.908-0.981; P = .003 and OR 0.94; CI = 0.91-0.98; P = .002 respectively). Multivariate analysis revealed the odds for reporting satisfaction for each decile increase in ADI were 0.96 for Total Score (CI = 0.921-0.998; P = .038) and 0.96 for Provider Sub-Score (CI = 0.92-0.993; P = .019). Patients in the most deprived quartile, compared to the least deprived, were significantly less likely to be satisfied with their care for both Total Score (OR 0.70; CI = 0.564-0.865; P = .001) and Provider Sub-Score (OR 0.69; CI = 0.558-0.852; P = .001).

CONCLUSIONS

Increased social deprivation was an independent predictor of lower patient satisfaction in otolaryngology outpatients using the Press Ganey survey. This non-modifiable outcome should be taken into consideration when evaluating patient satisfaction scores and offers further support to the need of addressing and improving healthcare discrepancies in the field of otolaryngology.

LEVEL OF EVIDENCE

Level 3.

Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents?

BACKGROUND

Research has indicated that lower socioeconomic status is associated with delays in the treatment of anterior cruciate ligament (ACL) injuries; however, there is a paucity of literature evaluating its association with patient-reported outcomes (PROs). Using the Area Deprivation Index (ADI), a validated proxy for socioeconomic status, the study aimed to determine how relative socioeconomic disadvantage is related to PROs after primary ACL reconstruction (ACLR) in pediatric patients.

METHODS

This retrospective cohort study included all patients 18 years old or above who underwent primary ACLR at an academic institution between 2018 and 2021. Exclusion criteria included multiligament injury, congenital ACL absence, and absent outcomes data. The minimum follow-up was 6 months. A Patient-reported Outcomes Measurement Information System (PROMIS) 50 Pediatric self-report questionnaire was completed at postoperative visits, and domain scores for pain, physical function/mobility, fatigue, anxiety, depression, and peer relationships were generated. The National ADI percentile was calculated using the patients' addresses. Patients were divided into quartiles (low, moderate, moderate-severe, and severe ADI), and comparative analyses were performed to determine the relationship between ADI and PROMIS.

RESULTS

A total of 413 patients were identified, including 49% (n=207), 33% (n=139), 11% (n=48), and 7% (n=30) from the low, moderate, moderate-severe, and severe deprivation areas, respectively. As compared with those in the low-deprivation quartile, patients in the severe deprivation quartile had delayed time to the first clinic visit (11 vs. 16.5 d, P=0.044) and surgery (51 vs. 80 d, P=0.004). There were no differences in the number of additional procedures required at index surgery. All quartiles had progressive improvements in physical function/mobility and pain scores throughout recovery, but at 9 months, there was significantly more pain in the severe deprivation cohort, despite no difference in self-reported physical function and mobility. Those with severe socioeconomic disadvantage had worse psychosocial outcomes, including significantly increased depression, fatigue, and anxiety and decreased peer relationship scores.

CONCLUSIONS

Although there were no differences in preoperative PROMIS scores, pediatric patients living in areas with higher levels of socioeconomic deprivation/disadvantage had worse psychosocial PROs after ACLR.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Assessment of neighborhood-level disadvantage and pediatric obstructive sleep apnea severity

Objectives

To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children.

Methods

A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy.

Results

Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38).

Conclusions

The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study.

Level of Evidence

Level 4.

Socioeconomic Deprivation and its Associations With Follow-up Compliance After In Situ Pinning of Slipped Capital Femoral Epiphysis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a common cause of hip pain in adolescents and is most often treated by in situ screw fixation. Orthopaedic follow-up is critical after treatment for SCFE due to risks of complications and subsequent contralateral slip. Recent studies have shown that socioeconomic deprivation is associated with decreased fracture care compliance, but no studies have explored this relationship with SCFEs. The study aims to determine the relationship between socioeconomic deprivation and SCFE follow-up care compliance.

METHODS

This study included pediatric patients treated with in situ pinning of SCFE between 2011 and 2019 at a single tertiary-care urban children's hospital. Demographic and clinical information were obtained from electronic medical records. The Area Deprivation Index (ADI) was used to quantify the socioeconomic deprivation of each. Outcome variables included patient age and status of physeal closure at the most recent appointment, in addition to the length of follow-up (mo). Statistical relationships were evaluated using nonparametric bivariate analysis and correlation.

RESULTS

We identified 247 evaluable patients; 57.1% were male, and the median age was 12.4 years. Most slips were stable (95.1%) and treated with isolated unilateral pinning (55.9%). Median length of follow-up was 11.9 months (interquartile range, 4.95 to 23.1) with median patient age at final visit of 13.6 years (interquartile range, 12.4 to 15.1). Only 37.2% of patients were followed until physeal closure. The mean ADI spread in this sample was similar to the national distribution. However, patients in the most deprived quartile were lost to follow-up significantly earlier (median, 6.5 mo) than those in the least deprived quartile (median, 12.5 mo; P <0.001). Throughout the entire cohort, there was a significant, inverse relationship between deprivation and follow-up length ( rs (238) = -0.3; P <0.001), with this relationship most pronounced in the most deprived quartile.

CONCLUSIONS

In this sample, ADI spread was representative of national trends, and the incidence of SCFE was distributed evenly across deprivation quartiles. However, follow-up length does not mirror this relationship; increased socioeconomic deprivation is associated with an earlier loss to follow-up (often well before physeal closure).

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic?

BACKGROUND

The 2019 novel coronavirus (COVID-19) pandemic has been associated with poor mental health outcomes and widened health disparities in the United States. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery, it is important that we understand whether patients presenting for musculoskeletal care during the pandemic were associated with worse physical and mental health than before the pandemic's onset.

QUESTIONS/PURPOSES

(1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, and/or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores?

METHODS

This was a retrospective, comparative study of new patient evaluations that occurred in the orthopaedic department at a large, urban tertiary care academic medical center. During the study period, PROMIS computer adaptive tests were routinely administered to patients at clinical visits. Between January 1, 2019, and December 31, 2019, we identified 26,989 new patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest. This left us with 11,660 patients in the "before COVID-19" cohort. Between January 1, 2021 and December 31, 2021, we identified 30,414 new patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the "during COVID-19" cohort. Nine-digit home ZIP Codes were used to determine patients' Area Deprivation Indexes, a neighborhood-level composite measure of social deprivation. To ensure that patients included in the study represented our overall patient population, we performed univariate analyses on available demographic and PROMIS data between patients included in the study and those excluded from the study, which revealed no differences (results not shown). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 46 ± 25. The main outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). PROMIS scores follow a normal distribution with a mean t-score of 50 and a standard deviation of 10. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively. Clinically meaningful differences in PROMIS scores between the cohorts were based on a minimum clinically important difference (MCID) threshold of 4 points. Multivariable linear regression models were created to determine whether presentation to an orthopaedic provider during the pandemic was associated with worse PROMIS scores than for patients who presented before the pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant.

RESULTS

We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% confidence interval -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001). Although patients from areas with high levels of social deprivation had worse PROMIS scores than patients from areas with low levels of social deprivation, patients from areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02).

CONCLUSION

Contrary to studies describing worse physical and mental health since the onset of the COVID-19 pandemic, we found no changes in the health status of orthopaedic patients on initial presentation to their provider. Although large-scale action to mitigate the effects of worsening physical or mental health of orthopaedic patients may not be needed at this time, orthopaedic providers should remain aware of the psychosocial needs of their patients and advocate on behalf of those who may benefit from intervention. Our study is limited in part to patients who had the self-agency to access specialty orthopaedic care, and therefore may underestimate the true changes in the physical or mental health status of all patients with musculoskeletal conditions. Future longitudinal studies evaluating the impact of specific COVID-19-related factors (for example, delays in medical care, social isolation, or financial loss) on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters.

LEVEL OF EVIDENCE

Level II, prognostic study.

Orthopaedic Diagnoses in the Black Pediatric Population

The Black pediatric population is one that has been historically underserved and continues to have unmet needs. Factors including lack of diversity in orthopaedic studies and in historical standards, such as bone age, may inadvertently lead to inferior care. There are certain conditions in this population for which the practicing orthopaedic surgeon should have a higher degree of suspicion, including slipped capital femoral epiphysis, Blount disease, and postaxial polydactyly. Systemic diseases with higher rates in this population have orthopaedic manifestations, including sickle cell disease, vitamin D deficiency, and obesity. Racial discrepancies in access to prenatal care can have orthopaedic consequences for babies, especially cerebral palsy and myelodysplasia. Racial discrepancy exists in evaluation for nonaccidental trauma. Increased awareness of these issues better prepares practitioners to provide equitable care.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences

PURPOSE

Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities.

METHODS

Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected.

RESULTS

The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity.

CONCLUSIONS

In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers.

CLINICAL RELEVANCE

As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome

PURPOSE

The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome.

METHODS

A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods.

RESULTS

A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error.

CONCLUSIONS

The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms.

CLINICAL RELEVANCE

Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Socioeconomic Factors and Pediatric Injury

Purpose of Review

The goal of this review is to describe how socioeconomic status (SES) is evaluated in the pediatric trauma literature and further consider how differences in SES can lead to inequities in pediatric injury.

Recent Findings

Insurance status, area-level income, and indices of socioeconomic deprivation are the most common assessments of socioeconomic status. Children from socioeconomically disadvantaged backgrounds experience higher rates of firearm-related injuries, motor vehicle-related injuries, and violence-related injuries, contributing to inequities in morbidity and mortality after pediatric injury. Differences in SES may also lead to inequities in post-injury care and recovery, with higher rates of readmission, recidivism, and PTSD for children from socioeconomically disadvantaged backgrounds.

Summary

Additional research looking at family-level measures of SES and more granular measures of neighborhood deprivation are needed. SES can serve as an upstream target for interventions to reduce pediatric injury and narrow the equity gap.

Association Between Neighborhood-Level Socioeconomic Disadvantage and Patient-Reported Outcomes in Lumbar Spine Surgery

BACKGROUND

Despite an increased understanding of the impact of socioeconomic status on neurosurgical outcomes, the impact of neighborhood-level social determinants on lumbar spine surgery patient-reported outcomes remains unknown.

OBJECTIVE

To evaluate the impact of geographic social deprivation on physical and mental health of lumbar surgery patients.

METHODS

A single-center retrospective cohort study analyzing patients undergoing lumbar surgery for degenerative disease from 2015 to 2018 was performed. Surgeries were categorized as decompression only or decompression with fusion. The area deprivation index was used to define social deprivation. Study outcomes included preoperative and change in Patient-Reported Outcomes Measurement (PROMIS) physical function (PF), pain interference (PI), depression, and anxiety (mean follow-up: 43.3 weeks). Multivariable imputation was performed for missing data. One-way analysis of variance and multivariable linear regression were used to evaluate the association between area deprivation index and PROMIS scores.

RESULTS

In our cohort of 2010 patients, those with the greatest social deprivation had significantly worse mean preoperative PROMIS scores compared with the least-deprived cohort (mean difference [95% CI]-PF: -2.5 [-3.7 to -1.4]; PI: 3.0 [2.0-4.1]; depression: 5.5 [3.4-7.5]; anxiety: 6.0 [3.8-8.2], all P < .001), without significant differences in change in these domains at latest follow-up (PF: +0.5 [-1.2 to 2.2]; PI: -0.2 [-1.7 to 2.1]; depression: -2 [-4.0 to 0.1]; anxiety: -2.6 [-4.9 to 0.4], all P > .05).

CONCLUSION

Lumbar spine surgery patients with greater social deprivation present with worse preoperative physical and mental health but experience comparable benefit from surgery than patients with less deprivation, emphasizing the need to further understand social and health factors that may affect both disease severity and access to care.

PROMIS Utilization in Pediatric Orthopaedics: A Scoping Review

BACKGROUND

The lack of a common patient-reported outcome metric used among the orthopaedic population is a problem that has been previously identified by the American Academy of Orthopaedic Surgeons. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health with the goal of creating a precise and efficient measurement tool for patient-reported symptoms, functioning, and health-related quality of life to be used in clinical research. A study summarizing its use in the pediatric orthopaedic population has not been previously performed.

METHODS

We performed a literature search of Ovid Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 2010 to August 2021. There were 1961 unique citations included after the removal of 1756 duplicates. After initial screening, 183 studies were screened under full-text review leaving a final number of 51 studies included in this scoping review.

RESULTS

Pediatric PROMIS studies were grouped by body part or sub-speciality: "Hand and Upper Extremity" (25.5%, n=13), "Sports" (23.5%, n=12), "Spine" (13.7%, n=7), "Trauma" (13.7%, n=7), "General Pediatric Orthopaedics" (11.8%, n=6), "Lower Extremity" (9.8%, n=5), and "Orthopaedic Oncology" (2%, n=1). An increase in studies utilizing PROMIS was seen throughout the study period with only 3 studies published from 2013 to 2016 to 39 in 2020 and 2021 alone. The 3 most frequently used pediatric PROMIS domains were Pain Interference (76.5%, n=39/51), Mobility (60.8%, n=31/51), and Upper Extremity (54.9%, n=28/51). 64.3% (n=9/14) of the included studies which reported on the floor effects of Pain Interference exhibited a significant floor effect. In all, 77.8% (n=7/9) of the included studies which reported on ceiling effects of Upper Extremity exhibited a significant ceiling effect.

CONCLUSION

The use of PROMIS increased significantly since the first publication in 2013 suggesting orthopaedic providers have increasingly utilized PROMIS in their day-to-day practice as an outcome measure. Ceiling and floor effects were prominent in several of the included domains (Pain Interference and Upper Extremity). Overall, PROMIS measures are efficient, reliable, and effective to use.

LEVEL OF EVIDENCE

IV.

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty

BACKGROUND

Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA.

RESULTS

Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA.

CONCLUSION

TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

METHODS

We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

RESULTS

A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

CONCLUSIONS

Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

LEVEL OF EVIDENCE

Level IV-narrative review.

Patient-Reported Outcome Measurement Information System (PROMIS) Scores in Pediatric Idiopathic Toe Walkers

BACKGROUND

Idiopathic toe walking (ITW) can result in early contact with the health care system and be distressing for patients and their families. The natural history of ITW is poorly characterized. Deciding how and when to intervene can be difficult.Patient-reported outcomes are utilized in the clinical setting to assess patient factors and indications that may better inform treatment plans. Patient-Reported Outcomes Measurement Information System (PROMIS) is an instrument designed to collect patient-reported outcomes. Minimum clinically important differences in PROMIS metrics have been established to facilitate clinical relevance and utility of these metrics. The purpose of this study was to characterize the patient perspective of ITW by utilizing the PROMIS scores.

METHODS

Retrospective chart review was performed to identify children aged 5 to 17 with a diagnosis of ITW treated at a single tertiary care center between 2017 and 2020. Inclusion criteria were a diagnosis of ITW and completion of a PROMIS questionnaire. Exclusion criteria were neurologic disease, autism, and previous surgical treatment. Demographic, physical exam, treatment, and available motion analysis data were collected. PROMIS scores for the following domains were available: Mobility, Peer Relationships, and Pain Interference.

RESULTS

Forty-five children were enrolled. Seventy-three percent of PROMIS scores were patient reported while the remainder were parent reported. PROMIS score means for the cohort by domain were Mobility: 45.2±8.2 ( P <0.000); Peer Relationships: 46.4±11.6 ( P =0.047); and Pain Interference: 47.4±9.5 ( P =0.67). Motion analysis data, available for 11 children, noted age-matched gait velocity negatively correlated ( rs =-0.652, P =0.03) with Peer Relationships. No correlations were found between other aspects of gait, body mass index, or limitations in dorsiflexion and PROMIS domains. Parents reported lower Mobility scores than children did. There were no other significant differences between patient-reported and parent-reported PROMIS scores. PROMIS scores did not differ significantly between those <10 years and those ≥10 years.

CONCLUSION

In this cohort of 45 otherwise healthy children without other neurologic diagnoses, there are both clinically and statistically significant differences in PROMIS means between our cohort and the healthy age-matched population. These differences manifested in worse peer relationships and mobility scores.

LEVEL OF EVIDENCE

Level IV.

Social and environmental determinants of health among children with long-term movement impairment

The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

PURPOSE

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

METHODS

We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

RESULTS

There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

CONCLUSIONS

Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The stigma of digital amputation: a survey of amputees with analysis of risk factors

The purpose of this study was to quantify the stigma associated with digital amputation and examine factors associated with it. One hundred and sixty-four digital amputees completed the Neurological Quality of Life-Stigma questionnaire and a battery of Patient-Reported Outcome Measurement Information System instruments. Multivariable analysis examined factors associated with stigma experience. The mean observed stigma score of 47 (SD 8, range 36-64) was similar to the mean value of the normal population. Younger age, a worker's compensation claim and depression were each independently associated with a more severe experience of stigma after digital amputation. Socioeconomic variables, anatomical details and mechanism of injury were not independently associated with stigma. Digital amputation is not highly stigmatizing overall. Surgeons should consider referring at-risk patients to a mental health provider for support during the coping and adjustment process after amputation.Level of evidence: III.

Evaluation of factors impacting patient satisfaction in a pediatric otolaryngology clinic

OBJECTIVES

With an emphasis on patient-centered care and provider transparency, patient satisfaction measures have become a key indicator of healthcare quality. Using the Press Ganey Outpatient Medical Practice Survey (PGOMPS), we sought to determine key factors that impact patient satisfaction.

METHODS

We conducted a retrospective review of new pediatric (<18 years old) outpatient otolaryngology visits between January 1, 2014 and December 31, 2018 at a children's hospital clinic and satellite clinics. Univariate and multivariate binary logistic regression analysis were used to determine factors correlated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.

RESULTS

A total of 1,050 patient or parent responses were included. The mean patient age was 5.6 ± 5.0 years with 54.7% identified as male. Univariate analysis demonstrated that for each 10-min increase in Total Wait Time, the odds of being satisfied were significantly decreased on both the Total Score (odds ratio [OR] 0.5; P < 0.001) and Provider Sub-Score (OR 0.8; P < 0.001). Furthermore, for each additional 5-year increase in patient age, patients were significantly more likely to report satisfaction on Total Score (OR 1.21; P = 0.011). Multivariate analysis revealed that the odds of achieving satisfaction for each decile increase in Total Wait Time were 0.5 for Total Score (P < 0.001) and 0.8 for Provider Sub-Score (P < 0.001), independent of patient age, sex, insurance category, socioeconomic disadvantage level, and patient community type.

CONCLUSIONS

Wait time is a significant factor impacting patients' likelihood of being satisfied with their overall care in a pediatric otolaryngology clinic setting.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

How Should We Measure Social Deprivation in Orthopaedic Patients?

BACKGROUND

Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions.

QUESTIONS/PURPOSES

(1) Which measure of social deprivation, defined as "limited access to society's resources due to poverty, discrimination, or other disadvantage," is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture?

METHODS

Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful.

RESULTS

Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains.

CONCLUSION

To capture the most variability due to social deprivation in orthopaedic patients' self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider accounting for insurance classification and/or national Area Deprivation Index, both of which are freely available and can be obtained from data that are typically collected during routine clinical care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Association Between Psychological Factors and Outcomes After Distal Radius Fracture

PURPOSE

The aim of this study was to identify psychological factors associated with pain intensity and disability following distal radius fracture.

METHODS

We prospectively followed 216 adult patients with distal radius fracture for 9 months. Demographics, injury and treatment details, and psychological measures (Hospital Anxiety and Depression Score [HADS], Pain Catastrophizing Scale, Posttraumatic Stress Disorder Checklist-Civilian, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire Brief [IPQB], General Self-Efficacy Scale, and Recovery Locus of Control [RLOC]) were collected at enrollment. Multivariable linear regression was used to identify factors associated with Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and Likert pain scores.

RESULTS

Higher 10-week DASH scores were associated with increased age, the presence of a nerve pathology, increased HADS Depression subscale scores, increased IPQB scores, and lower RLOC scores. Higher 9-month DASH scores were associated with increased age, increased deprivation scores, increased numbers of medical comorbidities, a greater degree of radial shortening, increased HADS Depression subscale scores, and lower RLOC scores. A higher 10-week pain score was associated with increased deprivation and IPQB scores. A higher pain score at 9 months was associated with an increased number of medical comorbidities.

CONCLUSIONS

Psychosocial factors measured early after fracture are associated with pain and disability up to 9 months after distal radius fracture. Illness perception is a potentially modifiable psychological construct not previously studied in hand conditions. It may provide a suitable target for psychological interventions that could enhance recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice

OBJECTIVES

This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences.

METHODS

We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis.

RESULTS

Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale.

CONCLUSIONS

A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.

Equality in Hip Arthroscopy Outcomes Can Be Achieved Regardless of Patient Socioeconomic Status

BACKGROUND

Access to quality health care and treatment outcomes can be affected by patients' socioeconomic status (SES).

PURPOSE

To evaluate the effect of patient SES on patient-reported outcome measures (PROMs) after arthroscopic hip surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Demographic, radiographic, and intraoperative data were prospectively collected and retrospectively reviewed on all patients who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear between February 2008 and September 2017 at one institution. Patients were divided into 4 cohorts based on the Social Deprivation Index (SDI) of their zip code. SDI is a composite measure that quantifies the level of disadvantage in certain geographical areas. Patients had a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), International Hip Outcome Tool-12, and visual analog scale (VAS) for both pain and satisfaction. Rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for the mHHS, NAHS, and VAS pain score. Rates of secondary surgery were also recorded.

RESULTS

A total of 680 hips (616 patients) were included. The mean follow-up time for the entire cohort was 30.25 months. Division of the cohort into quartiles based on the SDI national averages yielded 254 hips (37.4%) in group 1, 184 (27.1%) in group 2, 148 (21.8%) in group 3, and 94 (13.8%) in group 4. Group 1 contained the most affluent patients. There were significantly more men in group 4 than in group 2, and the mean body mass index was greater in group 4 than in groups 1 and 2. There were no differences in preoperative radiographic measurements, intraoperative findings, or rates of concomitant procedures performed. All preoperative and postoperative PROMs were similar between the groups, as well as in the rates of achieving the MCID or PASS. No differences in the rate of secondary surgeries were reported.

CONCLUSION

Regardless of SES, patients were able to achieve significant improvements in several PROMs after hip arthroscopy for FAIS and labral tear at the minimum 2-year follow-up. Additionally, patients from all SES groups achieved clinically meaningful improvement at similar rates.

Demographic Disparities amongst Patients Receiving Carpal Tunnel Release: A Retrospective Review of 92,921 Patients

Despite strong evidence supporting the efficacy of surgical release for carpal tunnel syndrome (CTS), previous studies have suggested that surgery is not performed equally amongst races and sex. The purpose of this study was to investigate potential socioeconomic disparities in the surgical treatment for CTS.

Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study

Purpose

To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.

Methods

Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.

Results

At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker’s compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.

Conclusions

Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.

Type of study/level of evidence

Prognostic III.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Area Deprivation Index and Magnitude of Scoliosis at Presentation to a Tertiary Referral Scoliosis Clinic in Massachusetts

BACKGROUND

There is growing interest in identifying predictors of large scoliosis curves at initial presentation, but few data to guide such preventive efforts. The association of neighborhood socioeconomic deprivation with curve magnitude in this context has not been previously evaluated. The purpose of our study was to determine the correlation of socioeconomic deprivation with scoliosis curve magnitude at initial presentation. Secondarily, we assessed the correlation of body mass index (BMI) with curve severity.

METHODS

We retrospectively identified 202 patients presenting with adolescent idiopathic scoliosis to a single tertiary care center in Massachusetts from January 2015 to August 2018. The Area Deprivation Index (ADI), a validated composite measure of neighborhood socioeconomic deprivation, was calculated for each patient. Curve magnitude, age, sex, BMI, race, and insurance status were recorded. Pearson correlation was used to determine the association of the ADI and BMI with scoliosis severity.

RESULTS

There was no correlation between the ADI and the magnitude of scoliosis at presentation (r=0.055; P=0.43). Greater BMI was moderately correlated with increased scoliosis curve magnitude (r=0.28; P<0.001). There was no association between curve magnitude and patient age, sex, race, or insurance status.

CONCLUSIONS

The finding that neighborhood socioeconomic deprivation did not correlate with greater scoliosis severity at presentation may be suggestive of equitable access to specialized scoliosis care. Future research should determine whether this reassuring finding is unique to Massachusetts--a state with high rates of health insurance coverage--or generalizable to other US states. In addition, our study further corroborates the notion that greater BMI is associated with larger scoliosis curves, and calls for targeted interventions to facilitate early scoliosis detection in the growing childhood obese population.

LEVEL OF EVIDENCE

Level II-prognostic study and retrospective study.

Evaluation of Patient Expectations before Carpal Tunnel Release

Background:

Carpal tunnel release (CTR) is common, yet patient treatment expectations remain unclear. The primary purpose was to describe patient expectations before CTR. Secondarily, we aimed to identify factors influencing expectations.

Methods:

Included patients underwent unilateral or bilateral CTR between 2015 and 2017 at a single academic center. Expectations regarding the level of relief/improvement were queried. Area deprivation index (ADI) was used to measure social deprivation. Univariate and multivariable logistic regression identified factors associated with expecting great relief/improvement.

Results:

Of 307 included patients, mean age was 54 ± 16 years and 63% were women. Patients most commonly expected great (58%) or some (23%) relief/improvement. Few patients expected little (3%) or no (4%) relief/improvement, and 13% had no expectations. In the multivariable analysis, male sex, lower social deprivation, and lower BMI were associated with expecting great relief/improvement. Age, surgical technique (open versus endoscopic), use of the operating room versus procedure room, and preoperative factors (constant numbness, weakness/atrophy, duration of symptoms, and QuickDASH) were not associated with expectations.

Conclusions:

Most patients expect some to great improvement after CTR. This was independent of several factors with a known association with worse outcomes (advanced age, atrophy/weakness, and constant numbness). Male sex was associated with the expectation of great improvement, in which superior outcomes relative to females have not been borne out in the literature. These findings highlight patient counseling opportunities. The observed association between social deprivation and expectations warrants further investigation, as the socioeconomically disadvantaged experience worse healthcare outcomes in general.

The Relationship between Neighborhood Deprivation and Perceived Changes for Pain-Related Experiences among U.S. Patients with Chronic Low Back Pain during the COVID-19 Pandemic

OBJECTIVE

Disruptions caused by the COVID-19 pandemic could disproportionately affect the health of vulnerable populations, including patients experiencing persistent health conditions (i.e., chronic pain), along with populations living within deprived, lower socioeconomic areas. The current cross-sectional study characterized relationships between neighborhood deprivation and perceived changes in pain-related experiences during the COVID-19 pandemic (early-September to mid-October 2020) for adult patients (N = 97) with nonspecific chronic low back pain.

METHODS

We collected self-report perceived experiences from participants enrolled in an ongoing pragmatic randomized trial across medical centers within the Salt Lake City, Utah and Baltimore, Maryland metropolitans. The Area Deprivation Index (composite of 17 U.S. Census deprivation metrics) reflected neighborhood deprivation based on participants' zip codes.

RESULTS

Although those living in the neighborhoods with greater deprivation endorsed significantly poorer physical (pain severity, pain interference, physical functioning), mental (depression, anxiety), and social health during the pandemic, there were no significant differences for perceived changes in pain-related experiences (pain severity, pain interference, sleep quality) between levels of neighborhood deprivation since the onset of the pandemic. However, those in neighborhoods with greater deprivation endorsed disproportionately worse perceived changes in pain coping, social support, and mood since the pandemic.

CONCLUSIONS

The current findings offer evidence that changes in pain coping during the pandemic may be disproportionately worse for those living in deprived areas. Considering poorer pain coping may contribute to long-term consequences, the current findings suggest the need for further attention and intervention to reduce the negative affect of the pandemic for such vulnerable populations.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores

Background

Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS).

Methods

We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status).

Results

Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70–0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94–0.96; p < 0.001).

Conclusions

Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

ICF linking of patient-reported therapy goals for children with acquired upper extremity impairment

BACKGROUND

Patient reported outcome measures are used to evaluate hand therapy outcomes. Yet, limited evidence is available regarding the outcomes children desire from hand therapy.

PURPOSE

To determine the desired treatment outcomes of children with acquired upper extremity impairments.

STUDY DESIGN

Descriptive case series METHODS: Two raters independently applied International Classification of Function, Disability and Health (ICF) linking rules to the Canadian Occupational Performance goals of 151 children, age 6-18, receiving occupational therapy for acquired upper extremity impairments. Prevalence of the linked ICF codes was examined using frequency distributions. Kappa and the proportion of positive agreement assessed inter-rater agreement of the linked codes.

RESULTS

Following consensus, two independent raters linked 894 meaningful concepts to the study population's 501 goals derived from the Canadian Occupational Performance. Ninety-two unique ICF codes were linked to these 894 meaningful concepts. Twenty-three ICF codes account for 77.2% of the most frequently linked codes. For these top 23 codes, the greatest proportion (51.4%) of ICF codes are in the d4 mobility chapter representing specific constructs of hand and arm use. The second largest proportion (14.2%) of linked codes are in the d9 Community, society and civic life chapter aligning with participation in sports, music, performing arts and play. Within the d5 self-care chapter, the study population's top priorities included hair care, fitness and drinking. The primary concerns within the b body functions domain are reduced pain, improved joint mobility and strength.

CONCLUSION

The study population's top priorities align with specific dimensions of hand and arm use and participation in sports and fitness, performing arts, and play. Further research may elucidate alignment of these patient-desired outcomes and the item banks of commonly used patient reported outcome measurement scales in this population.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND

We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution.

QUESTIONS/PURPOSES

Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment?

METHODS

In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores.

RESULTS

Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (β 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (β 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (β -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment.

CONCLUSION

Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Social Deprivation and Congenital Upper Extremity Differences-An Assessment Using PROMIS

PURPOSE

Social deprivation, a measure of socioeconomic status, has been shown to negatively affect perceptions of orthopedic conditions and outcomes of treatment. The objective of this study was to assess whether social deprivation correlates with subjective assessment of function in pediatric patients with congenital hand differences.

METHODS

Patients enrolled in the Congenital Upper Limb Differences (CoULD) registry were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). The PROMIS scores for Pain Interference, Peer Relations, Anxiety, Depression, and Upper Extremity (UE) function were obtained for all patients 5 years and older at initial presentation. Social deprivation was determined by the Area Deprivation Index (ADI); the index ranges from 0 to 100 with higher scores being the most deprived. The PROMIS scores were correlated with the ADI for all patients.

RESULTS

Three hundred seventy-five pediatric patients with congenital UE differences were evaluated. Average age was 11 years, 56% were female, and 55% had bilateral involvement. Overall, PROMIS scores were within 1 SD of normal for Peer Relations, Pain, Depression, and Anxiety. However, child-reported scores for UE function (39) were more than 1 SD below the national average (50). The mean ADI for the cohort was lower than the national average, indicative of less deprivation, with 14% of patients in the most deprived national quartile. Children in the highest ADI quartile reported PROMIS scores that reflected higher Pain Interference (41 vs 45), lower Peer Relations (55 vs 50), higher Anxiety (44 vs 49), and higher Depression (43 vs 47) than children in the lowest ADI quartile.

CONCLUSIONS

The PROMIS scores were normal for psychosocial measures in children with congenital hand differences when evaluated as an entire cohort. However, child self-reported PROMIS scores for Pain Interference, Peer Relations, Anxiety, and Depression were worse in more socially deprived areas, suggesting more psychosocial challenges in these children.

CLINICAL RELEVANCE

Pediatric patients with congenital upper extremity differences in areas of higher social deprivation report lower psychosocial well-being. The care of these individuals must be considered within the context of their environment because they may be more at risk for negative outcomes secondary to environmental and societal stressors.

The Impact of Social Deprivation on Orthopaedic Outpatient Satisfaction Using the Press Ganey Outpatient Medical Practice Survey

INTRODUCTION

In orthopaedics, multiple factors (patient age, wait time, and depression) have been associated with lower Press Ganey Outpatient Medical Practice Survey (PGOMPS) patient satisfaction scores. We hypothesized that increased social deprivation is an independent predictor of lower patient satisfaction, as measured by the PGOMPS.

METHODS

We retrospectively reviewed unique new outpatient orthopaedic surgery visits between January 1, 2014, and December 31, 2016, at a single tertiary academic institution. Given the high ceiling effects, satisfaction was defined a priori as achieving a score above the 33rd percentile. Social deprivation was determined using the 2015 Area Deprivation Index (ADI). Univariate and multivariable binary logistic regressions were used to detect factors associated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.

RESULTS

Of the 4,881 included patients, the mean age was 53.3 ± 15.9 years, 59.3% were women, and mean ADI was 30.1 ± 19.2. Univariate analysis revealed a significantly decreased odds of achieving satisfaction on the Total Score for each decile increase in ADI (odds ratio [OR] 0.94; P < 0.001). Compared with the least deprived quartile, patients of the most deprived quartile were significantly less likely to report satisfaction for both the Total Score (OR 0.56; P = 0.001) and Provider Sub-Score (OR 0.63; P = 0.011). Multivariable analysis revealed that the odds of achieving satisfaction for each decile increase in ADI were 0.96 for the Total Score (P = 0.014) and 0.95 for the Provider Sub-Score (P = 0.004), independent of age, wait time, race, subspecialty, provider type, and the clinic setting.

CONCLUSIONS

Increased social deprivation was an independent predictor of orthopaedic outpatient dissatisfaction on the PGOMPS. These findings should be considered when interpreting patient satisfaction scores and lend further support in an effort to improve healthcare inequalities.

LEVEL OF EVIDENCE

Level III.

Rate of Surgery and Baseline Characteristics Associated With Surgery Progression in Young Athletes With Prearthritic Hip Disorders

Background:

Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes.

Purpose:

To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted variables included patients’ self-reported athlete status, decision to choose surgery within 1 year of evaluation, and baseline self-reported pain and functional scores on Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score.

Results:

Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were athletes. Athletes were no more likely to choose surgery than nonathletes (130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI, 0.78-1.25]). Among athletes, those who proceeded to surgery over conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95% CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%, RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI, 1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose surgery also reported worse baseline hip-specific symptoms on all HOOS subscales (mean difference, 10.8-17.7; P < .01 for all).

Conclusion:

Similar to nonathletes, just over half of athletes with PAHD chose surgical management within 1 year of evaluation. Many competitive athletes with PAHD continued with conservative management and deferred surgery, but more structural hip pathology and worse hip-related baseline physical impairment were associated with the choice to pursue surgery.

Socioeconomic Deprivation and Its Adverse Association with Adolescent Fracture Care Compliance

Background:

Socioeconomic deprivation increases fracture incidence in adolescents, but its impact on fracture care is unknown. The area deprivation index (ADI), which incorporates 17 factors from the U.S. Census, measures socioeconomic deprivation in neighborhoods. This investigation aimed to determine the impact of socioeconomic deprivation and other socioeconomic factors on fracture care compliance in adolescents.

Methods:

This study included patients who were 11 to 18 years of age and received fracture care at a single urban children’s hospital system between 2015 and 2017. Demographic information (sex, race, caregiver status, insurance type) and clinical information (mechanism of injury, type of treatment) were obtained. The ADI, which has a mean score of 100 points and a standard deviation of 20 points, was used to quantify socioeconomic deprivation for each patient’s neighborhood. The outcome variables related to compliance included the quantity of no-show visits at the orthopaedic clinic and delays in follow-up care of >1 week. Risk factors for suboptimal compliance were evaluated by bivariate analysis and multivariate logistic regression.

Results:

The cohort included 457 adolescents; 75.9% of the patients were male, and the median age was 16.1 years. The median ADI was 101.5 points (interquartile range, 86.3 to 114.9 points). Bivariate analyses demonstrated that higher ADI, black race, single-parent caregiver status, Medicaid insurance, non-sports mechanisms of injury, and surgical management are associated with suboptimal fracture care compliance. Adolescents from the most socially deprived regions were significantly more likely to have delays in care (33.8% compared with 20.1%; p = 0.037) and miss scheduled orthopaedic visits (29.9% compared with 7.1%; p < 0.001) compared with adolescents from the least deprived regions. ADI, Medicaid insurance, and initial presentation to the emergency department were independent predictors of suboptimal care compliance, when controlling for other variables.

Conclusions:

Socioeconomic deprivation is associated with an increased risk of suboptimal fracture care compliance in adolescents. Clinicians can utilize caregiver and insurance status to better understand the likelihood of fracture care compliance. These findings highlight the importance of understanding differences in each family’s ability to adhere to the recommended follow-up and of implementing measures to enhance compliance.

Use of PROMIS in Assessment of Children With Ponseti-treated Idiopathic Clubfoot: Better Scores With Greater Than 3 Years of Brace Use

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) is a well-validated tool used to measure health-related quality of life for children and adolescents with chronic medical conditions. The current study evaluates PROMIS scores in 3 domains for children with Ponseti-treated idiopathic clubfoot.

METHODS

This is a retrospective cohort study of 77 children, ages 5 to 16 years, treated by Ponseti protocol for idiopathic clubfoot. Three pediatric PROMIS domains (Mobility, Pain Interference, and Peer Relationships) were administered between April 2017 and June 2018. One-way analysis of variance with Bonferroni post hoc and independent sample t tests were performed to explore differences across PROMIS domain scores by sex, age, initial Dimeglio score, laterality, bracing duration, and whether the child underwent tibialis anterior transfer.

RESULTS

In the self-reported group (ages 8 to 16), mean T-scores for all 3 domains in both unilaterally and bilaterally affected groups were within the normal range, with respect to the general reference pediatric population. However, children with unilateral clubfoot had a significantly higher mean Mobility T-score (54.77) than children with bilateral clubfoot (47.81, P=0.005). Children with unilateral clubfoot also had significantly lower mean pain scores (39.16) than their bilateral counterparts (46.56, P=0.005). Children who had braced >36 months had a significantly higher mean Mobility T-score (53.68) than children who braced ≤36 months (46.28, P=0.004).In the proxy group (ages 5 to 7), mean T-scores for all 3 domains in both laterality groups were within the normal range, with respect to the reference population. Children who had braced >36 months had a significantly higher mean Mobility T-score (52.75 vs. 49.15, P=0.014) and lower Pain Interference score (43.04 vs. 49.15, P=0.020) than children who braced ≤36 months.

CONCLUSIONS

Children treated by Ponseti protocol for idiopathic clubfoot yielded PROMIS scores for Mobility, Pain Interference, and Peer Relationships domains similar to the reference population. Bracing duration >36 months and unilaterality were associated with less mobility impairment than their counterparts. These findings may help guide parent recommendations.

LEVEL OF EVIDENCE

Level III.

Upper Extremity Function, Peer Relationships, and Pain Interference: Evaluating the Biopsychosocial Model in a Pediatric Hand Surgery Population Using PROMIS

PURPOSE

The relationship between biopsychosocial factors and patient-reported function is less clear in pediatric than in adult hand surgery patients. Our primary hypothesis was that pain interference (PI) and peer relationships (PR) would demonstrate association with upper extremity function. Secondarily, we hypothesized that the magnitude of this effect would increase with age.

METHODS

Patients aged 5 to 17 years presenting to a tertiary academic clinic between October 2017 and January 2019 were included. The parent/guardian was administered the following instruments after indicating they, rather than the patient, were answering the questions on a tablet computer: Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Parent Proxy (PP) Computer Adaptive Test (CAT) v2.0, PROMIS PI PP CAT v2.0, and the PROMIS PR PP CAT v2.0. Ceiling/floor effects and Spearman correlations were calculated. Multivariable Tobit modeling was performed to determine whether biopsychosocial factors and upper extremity function were associated. Multivariable regression coefficients were compared between age cohorts using a separate multivariable model to evaluate the interaction between age and other predictors.

RESULTS

Of 139 included participants, the mean age was 11.7 ± 3.7 years and 50% were female. For patients 11 years of age or younger, UE was weakly correlated with PI (coefficient, -0.34; 95% confidence interval, -0.56 to -0.08) and was not correlated with PR. For patients older than 11 years, UE had moderate correlation with PI (coefficient, -0.60; 95% confidence interval, -0.72 to -0.45) and was not correlated with PR. Multivariable analysis demonstrated a significant negative association between PI and UE, with a significantly larger magnitude of effect for patients older than 11 years of age.

CONCLUSIONS

The biopsychosocial model applies to pediatric hand surgery patients. The association between greater pain interference and worse patient-reported upper extremity function, as assessed using parent proxy instruments, was significantly stronger for patients older than 11 years than those 11 years old or younger.

CLINICAL RELEVANCE

This study suggests that the biopsychosocial model applies to pediatric hand patients.

Do Patient Sociodemographic Factors Impact the PROMIS Scores Meeting the Patient-Acceptable Symptom State at the Initial Point of Care in Orthopaedic Foot and Ankle Patients?

BACKGROUND

Patient-reported outcome measures such as the Patient-Reported Outcomes Measurement Information System (PROMIS) allow surgeons to evaluate the most important outcomes to patients, including function, pain, and mental well-being. However, PROMIS does not provide surgeons with insight into whether patients are able to successfully cope with their level of physical and/or mental health limitations in day-to-day life; such understanding can be garnered using the Patient-acceptable Symptom State (PASS). It remains unclear whether or not the PASS status for a given patient and his or her health, as evaluated by PROMIS scores, differs based on sociodemographic factors; if it does, that could have important implications regarding interpretation of outcomes and fair delivery of care.

QUESTIONS/PURPOSES

In a tertiary-care foot and ankle practice, (1) Is the PASS associated with sociodemographic factors (age, gender, race, ethnicity, and income)? (2) Do PROMIS Physical Function (PF), Pain Interference (PI), and Depression scores differ based on income level? (3) Do PROMIS PF, PI, and Depression thresholds for the PASS differ based on income level?

METHODS

In this retrospective analysis of longitudinally obtained data, all patients with foot and ankle conditions who had new-patient visits (n = 2860) between February 2015 and December 2017 at a single tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression survey and answer the following single, validated, yes/no PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your functional impairment, do you consider that the current state of your foot and ankle is satisfactory?" Of the 2860 new foot and ankle patient visits, 21 patient visits (0.4%) were removed initially because all four outcome measures were not completed. An additional 225 patient visits (8%) were removed because the patient chart did not contain enough information to accurately geocode them; 15 patients visits (0.5%) were removed because the census block group median income data were not available. Lastly, two patient visits (0.1%) were removed because they were duplicates. This left a total of 2597 of 2860 possible patients (91%) in our study sample who had completed all three PROMIS domains and answered the PASS question. Patient sociodemographic factors such as age, gender, race, and ethnicity were recorded. Using census block groups as part of a geocoding method, the income bracket for each patient was recorded. A chi-square analysis was used to determine whether sociodemographic factors were associated with different PASS rates, two-way ANOVA analyses with pairwise comparisons were used to determine if PROMIS scores differed by income bracket, and a receiver operating characteristic (ROC) curve analysis was performed to determine PASS thresholds for the PROMIS score by income bracket. The minimum clinically important difference (MCID) for PROMIS PF in the literature in foot and ankle patients ranges from about 7.9 to 13.2 using anchor-based approaches and 4.5 to 4.7 using the ½ SD, distribution-based method. The MCID for PROMIS PI in the literature in foot and ankle patients ranges from about 5.5 to 12.4 using anchor-based approaches and about 4.1 to 4.3 using the ½ SD, distribution-based method. Both were considered when evaluating our findings. Such MCID cutoffs for PROMIS Depression are not as well established in the foot and ankle literature. Significance was set a priori at p < 0.05.

RESULTS

The only sociodemographic factor associated with differences in the proportion of patients achieving PASS was age (15% [312 of 2036] of patients aged 18-64 years versus 11% [60 of 561] of patients aged ≥ 65 years; p = 0.006). PROMIS PF (45 ± 10 for the ≥ USD 100,000 bracket versus 40 ± 10 for the ≤ USD 24,999 bracket, mean difference 5 [95% CI 3 to 7]; p < 0.001), PI (57 ± 8 for ≥ USD 100,000 versus 63 ± 7 for ≤ USD 24,999, mean difference -6 [95% CI -7 to -4]; p < 0.001), and Depression (46 ± 8 for the ≥ USD 100,000 bracket versus 51 ± 11 for ≤ USD 24,999, mean difference -5 [95% CI -7 to -3]; p < 0.001) scores were better for patients in the highest income bracket compared with those in the lowest income bracket. For PROMIS PF, the difference falls within the score change range deemed clinically important when using a ½ SD, distribution-based approach but not when using an anchor-based approach; however, the score difference for PROMIS PI falls within the score change range deemed clinically important for both approaches. The PASS threshold of the PROMIS PF for the highest income bracket was near the mean for the US population (49), while the PASS threshold of the PROMIS PF for the lowest income bracket was more than one SD below the US population mean (39). Similarly, the PASS threshold of the PROMIS PI differed by 6 points when the lowest and highest income brackets were compared. PROMIS Depression was unable to discriminate the PASS.

CONCLUSIONS

Discussions about functional and pain goals may need to be a greater focus of clinic encounters in the elderly population to ensure that patients understand the risks and benefits of given treatment options at their advanced age. Further, when using PASS in clinical encounters to evaluate patient satisfaction and the ability to cope at different symptom and functionality levels, surgeons should consider income status and its relationship to PASS. This knowledge may help surgeons approach patients with a better idea of patient expectations and which level of symptoms and functionality is satisfactory; this information can assist in ensuring that each patient's health goal is included in shared decision-making discussions. A better understanding of why patients with different income levels are satisfied and able to cope at different symptom and functionality levels is warranted and may best be accomplished using an epidemiologic survey approach.

LEVEL OF EVIDENCE

Level III, diagnostic study.