Higher Area Deprivation Index Is Associated With Greater Practice-initiated Perioperative Communication Workload in...

Although deficits in social determinants of health (SDOH) have been previously associated with adverse clinical outcomes after primary THA and TKA, their role in the perioperative communication workload remains poorly characterized. Even though it remains essential to appropriately identify and address modifiable SDOH before a procedure, orthopaedic practices must also have the resources to handle the coordination of care effectively. Understanding how deficiencies in SDOH can impact communication workload would help support effective resource planning and equitable patient engagement strategies, particularly as more perioperative management takes place outside the hospital setting.

(1) What are the differences in touchpoint utilization in patients who live in locations with varying Area Deprivation Index (ADI) scores, a surrogate measure for social deprivation? (2) Does social deprivation have an association with the length of stay (LOS) during primary total joint arthroplasty? (3) How are readmission rates and patient-reported outcome measures (PROMs) different in patients living in areas with varying degrees of social deprivation?

In this retrospective, comparative study, there were 92,801 patients who underwent primary, elective THA (43% [39,963]) or TKA (57% [52,837]) for osteoarthritis at one high-volume, urban, academic institution between January 2016 and December 2022. Of those, exclusions consisted of indications other than osteoarthritis (2% [1595]), no available ADI data (13% [12,302]), or loss to minimum 90-day postoperative follow-up and incomplete data (29% [26,836]). In all, 52,068 patients were included in the final analysis, with 43% (22,363) of patients undergoing primary THA and 57% (29,705) undergoing primary TKA. To determine the degree of social deprivation, the 2022 ADI was used and linked to patients' street addresses. Using the ADI national ranking from 1 to 100, with 1 representing the lowest level of disadvantage and 100 representing the highest level of disadvantage, patients were compared by ADI quartiles; Quartile 1 represented the least disadvantaged cohort and Quartile 4 represented the most disadvantaged cohort. Overall, the mean ± SD age was 66 ± 10 years, and the population consisted of 56% (29,333 of 52,068) women. Thirty-three percent (17,391 of 52,068) of patients were in ADI Quartile 1, 44% (22,944 of 52,068) were in Quartile 2, 17% (8650 of 52,068) were in Quartile 3, and 6% (3083 of 52,068) were in Quartile 4. The primary outcome measure was the number of touchpoints per patient, defined as the communication points (telephone or electronic messages) sent or received on behalf of the patient in relation to the total joint arthroplasty procedure. Touchpoints within the 30-day preoperative or 90-day postoperative periods of the primary THA or TKA were included. Secondary outcome measures included LOS, 90-day readmissions, and PROMs consisting of the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) and the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR). Changes in HOOS, JR and KOOS, JR scores were obtained for 34% (7627 of 22,363) and 35% (10,418 of 29,705) of patients who received THA and TKA, respectively. Unadjusted and adjusted binomial regression models were performed to assess the association of ADI quartiles with touchpoint quantity, assessed by whether touchpoints were incoming or outgoing.

After adjusting for age, gender, BMI, race and ethnicity, and year of surgery, the proportion of outgoing, staff-initiated touchpoints increased as the degree of social deprivation increased. Patients in ADI Quartile 4 demonstrated the greatest increase in outgoing touchpoints compared with Quartile 1 (incidence rate ratio [IRR] 1.17 [95% confidence interval (CI) 1.11 to 1.25]; p < 0.001). For every 100 touchpoints sent out to patients in Quartile 1, approximately 117 were sent to patients in Quartile 4. However, Quartile 4 had the lowest rate of incoming touchpoints compared with Quartile 1 (IRR 0.95 [95% CI 0.91 to 0.99]; p = 0.01). This translates to roughly 95 touchpoints received from patients in the most disadvantaged quartile for every 100 touchpoints received from patients in the least disadvantaged quartile. The mean ± SD LOS for primary total joint arthroplasty among patients in Quartile 4 was 1.7 ± 1.4 days, whereas patients in Quartile 1 had a mean LOS of 1.2 ± 1.0 days (p < 0.001). There was a stepwise decline in same-day discharge and LOS < 24 hours as the level of deprivation became more severe (p < 0.001). Patients in Quartile 4 were discharged the same day at lower rates compared with patients in Quartile 1 (7% [138 of 1894] versus 14% [1526 of 10,623]; p < 0.001). Patients in Quartile 4 had higher 90-day readmission rates at 4% (111 of 3083), whereas those in Quartile 1 had the lowest readmission rates at 3% (460 of 17,391) (p = 0.004). Similarly, readmission rates increased progressively as the level of deprivation became more severe. From those who completed preoperative and postoperative PROMs, the proportion of patients who achieved the minimum clinically important difference at 12 months did not differ across ADI quartiles for the KOOS, JR (p = 0.32) and the HOOS, JR (p = 0.67).

While the magnitude of the differences in outgoing and incoming touchpoints between ADI quartiles was modest, the differences point to consistent patterns that practices can use to inform equity-based resource allocation and targeted patient engagement strategies. Orthopaedic surgeons may consider neighborhood-level deprivation indices to anticipate communication needs and perioperative support. Targeting barriers to care before they impede postoperative care is essential for patients from more disadvantaged areas. This can be achieved through flexible preoperative education via telemedicine, transportation support, and focused staff outreach at predetermined intervals. Patients in less disadvantaged areas would benefit from self-service education to offload incoming communications. Future studies should investigate whether communication workload mediates the relationship between deprivation indices and postoperative outcomes, such as whether additional staff-initiated outreach is necessary for patients from more disadvantaged areas to achieve comparable PROM thresholds as those for patients from less disadvantaged neighborhoods.

Level III, therapeutic study.