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Hoffman A, Alvandi LM, Gjonbalaj E, Lo Y, Badrinath R, Fornari ED, Karkenny AJ. Child Opportunity Index and Diagnosis of Developmental Dysplasia of the Hip: Insights From a Children's Hospital Serving Disadvantaged Communities. J Am Acad Orthop Surg 2024; 32:807-813. [PMID: 38861723 DOI: 10.5435/jaaos-d-24-00417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/05/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Initiation of Pavlik harness treatment for developmental dysplasia of the hip (DDH) by 6 to 7 weeks of age predicts a higher rate of success. Child Opportunity Index (COI) 2.0 is a single metric designed to measure resources and conditions affecting children's healthy development. This study investigates COI in relation to the timing of DDH diagnosis. METHODS This is a retrospective cohort study on patients younger than 4 years diagnosed with DDH between 2016 and 2023, treated with a Pavlik harness, rigid hip abduction orthosis, and/or surgery. Demographic and clinical data were recorded, including date of first diagnostic imaging. Patients with syndromes, congenital anomalies, or neuromuscular disorders and those referred with an unknown date of first diagnostic imaging were excluded. A subgroup analysis of patients diagnosed at ≤6 weeks ("early") and >6 weeks ("late") was conducted. Statewide COI scores (total, three domains) and categorical quintile scores (very low, low, moderate, high, and very high) were recorded. RESULTS A total of 115 patients were included: 90 female infants (78%), with a median age of 32 days at diagnostic imaging. No notable difference was observed between median age at diagnosis for study patients in low or very low quintiles and those in moderate, high, or very high quintiles for COI total or domains. "Early" and "late" diagnosis subgroups did not differ markedly by COI total or domains, nor insurance type, race, or ethnicity. Subgroups differed markedly by race and insurance status. DISCUSSION In an urban children's hospital, COI did not differ markedly between patients diagnosed with DDH by ≤6 weeks and >6 weeks. This is the first study to pose this question on DDH in a population with predominantly low/very low COI scores and public insurance, which may lead to unexpected results. Replicating the study in a different setting could yield different results. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexandra Hoffman
- From the Albert Einstein College of Medicine (Hoffman, Lo), Montefiore-Einstein and The Children's Hospital at Montefiore (Alvandi,Gjonbalaj, Fornari, Karkenny), and Jacobi Medical Center, Bronx, NY (Badrinath)
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Yang D, Orellana K, Lee J, Bram J, Sarkar S, Renjilian CB, Ganley TJ. The Child Opportunity Index and Outcomes After Pediatric Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241248433. [PMID: 39351066 PMCID: PMC11440534 DOI: 10.1177/23259671241248433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 10/04/2024] Open
Abstract
Background Research at the intersection between social determinants of health (SDOH) and orthopaedics remains an area of active exploration, with recent literature demonstrating significant disparities in a wide array of orthopaedic outcomes in patients with different SDOH. Purpose/Hypothesis The purpose of this study was to use a validated composite measure of SDOH mapped to census tracts (Child Opportunity Index [COI]) to explore disparities in functional outcomes after anterior cruciate ligament (ACL) reconstruction. It was hypothesized that patients with a lower COI score would have delayed surgical care and worse functional outcomes after ACL reconstruction. Study Design Cohort study; Level of evidence, 3. Methods Demographic, surgical, and functional outcomes data were extracted for all patients aged ≤18 years who underwent primary ACL reconstruction at our institution between 2009 and 2019. Strength deficits were calculated, and COI quintile scores were obtained. One-way analysis of variance, the chi-square test, and the Fisher exact test were used to compare variables of interest between the lower 2 quintiles (low group) and the upper 2 quintiles (high group). Results Of the 1027 patients, 226 (22.0%) were in the low group, while 801 (78.0%) were in the high group. There was a significantly greater time from injury to surgery in the low group than in the high group (98.15 ± 102.65 vs 71.79 ± 101.88 days, respectively; P < .001). The low group had a significantly lower extension-flexion range of motion at 1- and 3-month follow-up (P = .03 and P = .02, respectively) but no difference at 6-month follow-up (P = .27). The low group attended fewer physical therapy visits than the high group (24.82 ± 10.55 vs 37.81 ± 18.07, respectively; P < .001). The low group had significant deficits in quadriceps strength at 3, 6, and 9 months at 180 deg/s (P = .03, P < .001, and P = .01, respectively) and at 6 months at 300 deg/s (P = .002). Conclusion In this study, we found that the COI was associated with disparities in key clinical outcomes including time to surgery, postoperative range of motion, and postoperative strength.
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Affiliation(s)
- Daniel Yang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin Orellana
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julianna Lee
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua Bram
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sulagna Sarkar
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Chacon MA, Cook CA, Flynn-O'Brien K, Zagory JA, Choi PM, Wilson NA. Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature. J Pediatr Surg 2024; 59:1378-1387. [PMID: 38631997 PMCID: PMC11164636 DOI: 10.1016/j.jpedsurg.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 04/19/2024]
Abstract
CONTEXT Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices. OBJECTIVE We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes. DATA SOURCES A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023). STUDY SELECTION Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric. DATA EXTRACTION Extraction domains included study, patient, and procedure characteristics. RESULTS Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent. LIMITATIONS All studies were retrospective and quality varied from good to fair. CONCLUSIONS While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care. TYPE OF STUDY Systematic Review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Miranda A Chacon
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA
| | - Caitlin A Cook
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA
| | - Katherine Flynn-O'Brien
- Division of Pediatric Surgery, Children's Wisconsin and Medical College of Wisconsin, 8915 W. Connell Ct., Milwaukee, WI 53226, USA
| | - Jessica A Zagory
- Division of Pediatric Surgery, Department of Surgery, Louisiana State University Health Sciences Center - New Orleans, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Pamela M Choi
- Department of Surgery, Naval Medical Center, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - Nicole A Wilson
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA; Department of Biomedical Engineering, University of Rochester, 601 Elmwood Ave, Box SURG, Rochester, NY 14642, USA.
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Dadoo S, Keeling LE, Engler ID, Chang AY, Runer A, Kaarre J, Irrgang JJ, Hughes JD, Musahl V. Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage. Br J Sports Med 2024; 58:649-654. [PMID: 38760154 DOI: 10.1136/bjsports-2023-107409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume. METHODS Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups. RESULTS The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair. CONCLUSION Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons. LEVEL OF EVIDENCE Retrospective cohort study, level III.
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Affiliation(s)
- Sahil Dadoo
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura E Keeling
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ian D Engler
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Central Maine Medical Center, Lewiston, Maine, USA
| | - Audrey Y Chang
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Armin Runer
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Sports Orthopaedics, Technical University of Munich, Munchen, Germany
| | - Janina Kaarre
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedics, Sahlgrenska Academy, Goteborg, Sweden
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedics, Sahlgrenska Academy, Goteborg, Sweden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Sliepka JM, Gatto J, Iyer A, Saper M, Schmale G, Gee A, Kweon C, Chin K, Hagen M. Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury. Orthop J Sports Med 2024; 12:23259671241235651. [PMID: 38515603 PMCID: PMC10956159 DOI: 10.1177/23259671241235651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 03/23/2024] Open
Abstract
Background In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time. Purpose To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears. Study Design Case-control study; Level of evidence, 3. Methods We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery. Results A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals. Conclusion Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.
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Affiliation(s)
- Joseph M. Sliepka
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathon Gatto
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Ananth Iyer
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael Saper
- Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Albert Gee
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher Kweon
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Kenneth Chin
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Mia Hagen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
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Orellana KJ, Lee J, Yang D, Hauth L, Flynn JM. Impact of Social Determinants of Health on Adolescent Idiopathic Scoliosis Curve Severity. J Pediatr Orthop 2024; 44:e168-e173. [PMID: 37796167 DOI: 10.1097/bpo.0000000000002529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Social determinants of health have been shown to influence the health and outcomes of pediatric patients. Adolescent idiopathic scoliosis (AIS) may be particularly sensitive to such factors as early diagnosis and treatment can obviate the need for surgical intervention. The purpose of this study was to analyze the effect that social determinants of health have on the severity of AIS at presentation and at the time of surgery. METHODS A retrospective review was conducted for consecutive patients who underwent posterior spinal fusion for AIS from 2020 to 2022. Demographic data was collected, while insurance status (private vs. public) and childhood opportunity index (COI) categories (LOW vs. HIGH) were used as a proxy for socioeconomic status. Curve magnitude at the initial presentation and at the latest preoperative visit were recorded with a threshold of 25 to 40 degrees considered within the bracing range. Univariate and multivariate analysis was done to compare differences between subgroups as appropriate. RESULTS A total of 180 patients with mean initial and preoperative major curve angles of 48 and 60 degrees were included. Statistically significant differences in race and insurance types were appreciated, with the LOW COI group having a higher proportion of underrepresented minority and publicly insured patients than the HIGH COI group ( P <0.001). Patients within the LOW COI group presented with an initial curve that was, on average, 6 degrees more severe than those within the HIGH group ( P =0.009) and a preoperative curve that was 4 degrees larger than those within the HIGH group ( P =0.015). Similarly, only 13% of patients within the LOW COI group presented with curves within the bracing threshold, compared with 31% in the HIGH COI group ( P =0.009). CONCLUSION Socioeconomic status plays a significant role in the severity of AIS. Specifically, patients with lower COI tend to present with curve magnitudes beyond what is responsive to nonsurgical treatment, leading to larger curves at the time of surgery. Future work should focus on addressing social inequalities to optimize the treatment and outcomes of AIS patients. LEVEL OF EVIDENCE Level III- Retrospective Comparative Study.
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Affiliation(s)
- Kevin J Orellana
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julianna Lee
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Daniel Yang
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lucas Hauth
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - John M Flynn
- Department of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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Kiani SN, England P, Gornitzky AL, Renjilian CB, Williams BA, Ganley TJ. Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents? J Pediatr Orthop 2023; 43:543-548. [PMID: 37694606 DOI: 10.1097/bpo.0000000000002491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
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.
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Affiliation(s)
- Sara N Kiani
- Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA
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Hartwell MJ. Editorial Commentary: Understanding the Gap in Clinical Outcomes After Rotator Cuff Repair Based on the Influence of Social Determinants of Health. Arthroscopy 2023; 39:243-244. [PMID: 36603994 DOI: 10.1016/j.arthro.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023]
Abstract
There is growing recognition and understanding of the important role that social determinants of health and access to care play in surgical outcomes, particularly in the field of orthopaedic surgery and sports medicine. Factors including race, ethnicity, education, income, insurance status, social class, and sex have been identified as important contributors to outcomes after orthopaedic procedures, including rotator cuff repair. Disadvantaged or marginalized patients have been shown to attend fewer office visits and physical therapy sessions, are more likely to present with advanced stages of disease, have delayed surgical interventions, and have poorer patient-reported outcomes after surgery. Virtual visits and telemedicine have the great ability to improve access to medical professionals for disadvantaged patients who have poor access to transportation. However, reliance on telehealth has the potential to worsen access to care for patients with limited access to technology or language barriers. Disadvantaged populations, including those with noncommercial health care insurance, show decreased use of telemedicine.
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