Relationship Between the Social Determinants of Health and Total Joint Arthroplasty Outcomes

Research Objective Social determinants of health (SDOH) are the conditions in one’s living environment that affect health, functioning, and quality of life. Total joint arthroplasty (TJA) is a surgical procedure to replace a damaged joint with an artificial joint. TJA complications include acute myocardial infarction, pneumonia, sepsis, surgical site bleeding, pulmonary embolism, or periprosthetic joint infection. Previous research demonstrates that Black race, Hispanic ethnicity and poverty were negatively associated with TJA outcomes in veterans. The goal of this mixed methods quality improvement study is to determine if SDOHs affect TJA complications at a health system in the Phoenix metropolitan area. Methodology For this study, records from patients who underwent hip or knee TJAs at any of the four system facilities between 2/2019-2/2020 were included. Demographics and clinical data were extracted from the electronic health record (EHR) via Midas+ Care Management with SDOH variables from case manager notes corresponding to food, utilities, housing and transportation insecurities, and interpersonal safety. Complications were identified using ICD-10 codes. SDOH for individuals with and without complications were compared. A multinomial logistic regression was performed in SPSS to identify significant variables. Semi-structured interviews with case managers (n=2), orthopedic surgeons(n=5), and primary care physicians (n=4) were performed to explore care team interactions with SDOH. Interview notes were coded and analyzed based on response frequency and themes. Results Of 2,520 patients who underwent TJA, 50 (1.98%) experienced a TJA complication. Of those, 38% screened positive for an SDOH. For those without a TJA complication, 27% screened positive for an SDOH (p=0.093). Most interview participants identified a correlation between socioeconomic status and surgical outcomes. They also recognized that language barriers for Spanish-speaking individuals and family involvement post-discharge are significant factors in TJA outcomes. Conclusions This single system mixed methods retrospective quality improvement study demonstrates that patients who screen positive for an SDOH are more likely to experience a TJA complication. We recommend that SDOH assessments be obtained for all patients undergoing TJA, be available to care teams, and be incorporated into care plans to improve outcomes.