Bonsel Joshua M, Reijman Max, Macri Erin M, Verhaar Jan A N, van Steenbergen Liza N, Bonsel Gouke J
Department of Orthopaedics and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands.
Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies), 's Hertogenbosch, The Netherlands.
Int J Equity Health. 2025 May 23;24(1):147. doi: 10.1186/s12939-025-02520-4.
Prior to total hip and knee arthroplasty (THA/TKA), patients with low socioeconomic status (SES) report worse Patient-Reported Outcome Measures (PROMs), persisting postoperatively. This study explores which self-reported PROMs and their specific domains are most involved.
We obtained data from the Dutch Arthroplasty Registry (2014-2022), including over 100,000 THA/TKA patients with complete preoperative and 12-month follow-up PROMs. The EQ-5D-3L and EQ-5D-5L, EQ Visual Analogue Scale (VAS), Oxford Hip and Oxford Knee Score (OHS/OKS), and Numerical Rating Scales (NRS) for pain and satisfaction (TKA only, at 12-month follow-up) were obtained. The PROMs were transformed to a 0-100 scale for direct comparison. A SES-indicator based on neighborhood income, unemployment rate, and education level was divided into quintiles, which are equal groups representing 20% of the Dutch population, and was ranked from least to most deprived. Through linear regression we contrasted the most and least deprived groups, adjusting for patient and surgical characteristics. The contribution (percentage) of each domain to the overall health inequalities was estimated for the EQ-5D's and the OHS/OKS.
In TKA patients, the most compared to the least deprived group had a lower preoperative EQ-5D-3L score: -2.1 [95% confidence interval - 2.6, -1.6], p < 0.001. At 12-month follow-up, the difference was smaller: EQ-5D-3L 1.3 [-1.9, -0.7], p < 0.001. A larger difference between the most and least deprived was present in OKS (preoperatively: -4.3 [-5.3, -3.4], p < 0.001; 12-month: -1.8 [-2.5, -1.2], p < 0.001). The difference in EQ VAS was smaller (preoperatively: -0.8 [-1.5, -0.1], p = 0.024; 12-month: -0.5 [-1.2, 0.1], p = 0.108). The difference in NRS pain (in rest) was comparable to those in EQ-5D-3L and OKS (preoperatively: -4.5 [-5.4, -3.5], p < 0.001; 12-month: -2.7 [-3.5, -1.9], p < 0.001), while no difference between the most and least deprived in NRS satisfaction was observed at 12 months. For EQ-5D-3L, the domain usual activities accounted for up to 46% of the difference between SES groups, while anxiety/depression played a limited role (up to 17%). For OHS/OKS, functioning contributed most in THA (up to 61%) and pain contributed most in TKA (up to 68%). Differences in PROM scores between SES groups, and how these differences compared across PROMs, were similar in THA patients. Overall, the EQ-5D-5L produced similar patterns compared to the EQ-5D-3L.
Deprived THA/TKA patients have poorer pre- and postoperative health, which was primarily related to worse functioning and pain; the clinical relevance of these differences remain uncertain. These differences did not translate into worse overall health (EQ VAS) or into higher dissatisfaction among deprived patients. Future research should investigate whether the EQ VAS and satisfaction measure reflected health differences between SES groups or were biased by reporting heterogeneity, where respondents interpreted the wording differently.
在全髋关节置换术和全膝关节置换术（THA/TKA）之前，社会经济地位（SES）较低的患者报告的患者报告结局指标（PROMs）较差，且术后仍持续存在。本研究探讨哪些自我报告的PROMs及其特定领域受影响最大。
我们从荷兰关节置换登记处（2014 - 2022年）获取数据，包括超过100,000例接受THA/TKA手术且术前和术后12个月PROMs完整的患者。获取了EQ - 5D - 3L和EQ - 5D - 5L、EQ视觉模拟量表（VAS）、牛津髋关节和牛津膝关节评分（OHS/OKS）以及疼痛和满意度的数字评定量表（NRS，仅适用于TKA，在术后12个月）。将PROMs转换为0 - 100分制以便直接比较。基于邻里收入、失业率和教育水平的SES指标被分为五个五分位数，这是代表20%荷兰人口的相等组，且从最贫困到最不贫困进行排序。通过线性回归，我们对比了最贫困和最不贫困组，并对患者和手术特征进行了调整。针对EQ - 5D和OHS/OKS，估计了每个领域对总体健康不平等的贡献（百分比）。
在TKA患者中，最贫困组与最不贫困组相比，术前EQ - 5D - 3L得分较低：-2.1 [95%置信区间 - 2.6，-1.6]，p < 0.001。在术后12个月随访时，差异较小：EQ - 5D - 3L为1.3 [-1.9，-0.7]，p < 0. .001。OKS中最贫困组与最不贫困组之间的差异更大（术前：-4.3 [-5.3，-3.4]，p < 0.001；术后12个月：-1.8 [-2.5，-1.2]，p < 0.001）。EQ VAS的差异较小（术前：-0.8 [-1.5，-0.1]，p = 0.024；术后12个月：-0.5 [-1.2，0.1]，p = 0.108）。NRS疼痛（静息时）的差异与EQ - 5D - 3L和OKS中的差异相当（术前：-4.5 [-5.4，-3.5]，p < 0.001；术后12个月：-2.7 [-3.5，-1.9]，p < 0.001），而在术后12个月时，最贫困组与最不贫困组在NRS满意度方面未观察到差异。对于EQ - 5D - 3L，日常活动领域在SES组之间的差异中占比高达46%，而焦虑/抑郁的作用有限（高达17%）。对于OHS/OKS，在THA中功能的贡献最大（高达61%），在TKA中疼痛的贡献最大（高达68%）。SES组之间PROM得分的差异以及这些差异在不同PROMs之间的比较在THA患者中相似。总体而言，与EQ - 5D - 3L相比，EQ - 5D - 5L产生了相似的模式。
贫困的THA/TKA患者术前和术后健康状况较差，这主要与功能较差和疼痛有关；这些差异的临床相关性仍不确定。这些差异并未转化为总体健康状况更差（EQ VAS）或贫困患者更高的不满。未来的研究应调查EQ VAS和满意度测量是否反映了SES组之间的健康差异，或者是否受到报告异质性的影响，即受访者对措辞的理解不同。
