M. A. Wright, M. Adelani, C. Dy, R. O'Keefe, R. P. Calfee, Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, MO, USA.
Clin Orthop Relat Res. 2019 Aug;477(8):1825-1835. doi: 10.1097/CORR.0000000000000698.
The complex interrelationship among physical health, mental health, and social health has gained the attention of the medical community in recent years. Poor social health, also called social deprivation, has been linked to more disease and a more-negative impact from disease across a wide variety of health conditions. However, it remains unknown how social deprivation is related to physical and mental health in patients presenting for orthopaedic care.
QUESTIONS/PURPOSES: (1) Do patients living in zip codes with higher social deprivation report lower levels of physical function and higher levels of pain interference, depression, and anxiety as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) at initial presentation to an orthopaedic provider than those from less deprived areas; and if so, is this relationship independent of other potentially confounding factors such as age, sex, and race? (2) Does the relationship between the level of social deprivation of a patient's community and that patient's physical function, pain interference, depression, and anxiety, as measured by PROMIS remain consistent across all orthopaedic subspecialties? (3) Are there differences in the proportion of individuals from areas of high and low levels of social deprivation seen by the various orthopaedic subspecialties at one large, tertiary orthopaedic referral center?
This cross-sectional evaluation analyzed 7500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index, a composite measure of community-level social deprivation, based on multiple census metrics such as income, education level, and housing type for a given nine-digit zip code was used to estimate individual social deprivation. Statistical analysis determined the effect of disparate area deprivation (based on most- and least-deprived national quartiles) for the entire sample as well as for patients categorized by the orthopaedic subspecialty providing care. Comparisons of PROMIS scores among these groups were based on an MCID of 5 points for each PROMIS domain (Effect size 0.5).
Patients living in zip codes with the highest levels of social deprivation had worse mean scores across all four PROMIS domains when compared with those living in the least-deprived quartile (physical function 38 +/- 9 versus 43 +/- 9, mean difference 4, 95% CI, 3.7-5.0; p < 0.001; pain interference 64 +/- 8 versus 60+/-8, mean difference -4, 95% CI, -4.8 to -3.7; p < 0.001; depression 50+/-11 versus 45+/-8, mean difference -5, 95% CI, -6.0 to -4.5; p < 0.001; anxiety 56+/-11 versus 50 +/-10, mean difference -6, 95% CI, -6.9 to -5.4; p < 0.001). There were no differences in physical function, pain interference, depression, or anxiety PROMIS scores between patients from the most- and least-deprived quartiles who presented to the subspecialties of spine (physical function, mean 35+/-7 versus 35+/-7; p = 0.872; pain interference, 67+/-7 versus 66+/-7; p = 0.562; depression, 54+/-12 versus 51 +/-10; p = 0.085; and anxiety, 60+/-11 versus 58 +/-9; p = 0.163), oncology (physical function, mean 33+/-9 versus 38 +/-13; p = 0.105; pain interference, 68+/-9 versus 64+/-10; p = 0.144; depression, 51+/-10 versus 52+/-13; p = 0.832; anxiety, 59+/-11 versus 59+/-10 p = 0.947); and trauma (physical function, 35+/-11 versus 32+/-10; p = 0.268; pain interference, 66+/-7 versus 67+/-6; p = 0.566; depression, 52+/-12 versus 53+/-11; p = 0.637; and anxiety, 59+/-12 versus 60+/-9 versus; p = 0.800). The social deprivation-based differences in all PROMIS domains remained for the subspecialties of foot/ankle, where mean differences ranged from 3 to 6 points on the PROMIS domains (p < 0.001 for all four domains), joint reconstruction where mean differences ranged from 4 to 7 points on the PROMIS domains (p < 0.001 for all four domains), sports medicine where mean differences in PROMIS scores ranged from 3 to 5 between quartiles (p < 0.001 for all four domains), and finally upper extremity where mean differences in PROMIS scores between the most- and least-deprived quartiles were five points for each PROMIS domain (p < 0.001 for all four domains). The proportion of individuals from the most- and least-deprived quartiles was distinct when looking across all seven subspecialty categories; only 11% of patients presenting to sports medicine providers and 17% of patients presenting to upper extremity providers were from the most-deprived quartile, while 39% of trauma patients were from the most-deprived quartile (p < 0.001).
Orthopaedic patients must be considered within the context of their social environment because it influences patient-reported physical and mental health as well as has potential implications for treatment and prognosis. Social deprivation may need to be considered when using patient-reported outcomes to judge the value of care delivered between practices or across specialties. Further studies should examine potential interventions to improve the perceived health of patients residing in communities with greater social deprivation and to determine how social health influences ultimate orthopaedic treatment outcomes.
Level II, prognostic study.
近年来，医学领域越来越关注身体健康、心理健康和社会健康之间的复杂关系。较差的社会健康，也称为社会剥夺，与各种健康状况下更多的疾病和更严重的疾病影响有关。然而，目前尚不清楚社会剥夺与接受骨科护理的患者的身心健康之间存在何种关系。
问题/目的：（1）在初次就诊于骨科医生时，邮政编码地区社会剥夺程度较高的患者报告的身体功能水平和疼痛干扰程度、抑郁和焦虑程度是否低于社会剥夺程度较低地区的患者，其程度由患者报告的结局测量信息系统（PROMIS）测量；如果是这样，这种关系是否独立于其他潜在的混杂因素，如年龄、性别和种族？（2）患者所在社区的社会剥夺程度与患者的身体功能、疼痛干扰、抑郁和焦虑之间的关系，由 PROMIS 测量，在所有骨科亚专科中是否保持一致？（3）在一家大型三级骨科转诊中心，各个骨科亚专科看到的社会剥夺程度较高和较低地区的个体比例是否存在差异？
本横断面研究分析了 2016 年 8 月 1 日至 2016 年 12 月 15 日期间在骨科中心就诊的 7500 名新成年患者。患者完成了 PROMIS 身体功能 v1.2、疼痛干扰 v1.1、抑郁 v1.0 和焦虑 v1.0 计算机自适应测试。区域剥夺指数是一种基于收入、教育水平和给定九位数邮政编码住房类型等多项人口普查指标的社区级社会剥夺综合衡量标准，用于估计个体社会剥夺程度。统计分析确定了整个样本以及按提供护理的骨科亚专科分类的患者之间不同地区剥夺程度（基于最和最不剥夺的全国四分位数）的影响。对这些组的 PROMIS 评分进行比较的依据是每个 PROMIS 域的 5 分差异（效应大小 0.5）。
与生活在最不贫困四分之一地区的患者相比，生活在邮政编码地区社会剥夺程度最高地区的患者在所有四个 PROMIS 领域的平均得分都较差（身体功能 38 +/- 9 与 43 +/- 9，平均差异 4，95%置信区间，3.7-5.0；p < 0.001；疼痛干扰 64 +/- 8 与 60+/-8，平均差异-4，95%置信区间，-4.8 至-3.7；p < 0.001；抑郁 50+/-11 与 45+/-8，平均差异-5，95%置信区间，-6.0 至-4.5；p < 0.001；焦虑 56+/-11 与 50 +/-10，平均差异-6，95%置信区间，-6.9 至-5.4；p < 0.001）。在接受脊柱（身体功能，平均 35 +/-7 与 35 +/-7；p = 0.872；疼痛干扰，67 +/-7 与 66 +/-7；p = 0.562；抑郁，54 +/-12 与 51 +/-10；p = 0.085；焦虑，60 +/-11 与 58 +/-9；p = 0.163）、肿瘤（身体功能，平均 33 +/-9 与 38 +/-13；p = 0.105；疼痛干扰，68 +/-9 与 64+/-10；p = 0.144；抑郁，51 +/-10 与 52 +/-13；p = 0.832；焦虑，59 +/-11 与 59 +/-10 p = 0.947）和创伤（身体功能，35+/-11 与 32+/-10；p = 0.268；疼痛干扰，66 +/-7 与 67 +/-6；p = 0.566；抑郁，52 +/-12 与 53 +/-11；p = 0.637；焦虑，59 +/-12 与 60+/-9；p = 0.800）亚专科的患者中，这种 PROMIS 各领域的社会剥夺差异仍然存在。在足踝、关节重建、运动医学和上肢亚专科中，PROMIS 各领域的平均差异范围为 3 至 6 分（所有四个领域均 p < 0.001）。在运动医学中，PROMIS 评分在四分位数之间的差异范围为 3 至 5 分（所有四个领域均 p < 0.001），而在上肢亚专科中，最不贫困和最贫困四分位数之间的 PROMIS 评分差异为每个 PROMIS 域 5 分（所有四个域均 p < 0.001）。在所有七个亚专科类别中，最贫困和最贫困四分位数患者的比例差异显著；只有 11%的运动医学患者和 17%的上肢患者来自最贫困四分位数，而 39%的创伤患者来自最贫困四分位数（p < 0.001）。
骨科患者必须在其社会环境中考虑，因为它会影响患者报告的身心健康，并且对治疗和预后具有潜在影响。在使用患者报告的结局来判断不同实践或专业之间的护理价值时，可能需要考虑社会剥夺。应进一步研究潜在的干预措施，以改善居住在社会剥夺程度较高社区的患者的健康感知，并确定社会健康如何影响最终的骨科治疗结果。
II 级，预后研究。
