SOCIAL DETERMINANTS OF HEALTH

Twenty-one low quality articles were included and analyzed for this option.

Ten of these articles (Delanois 2022, Edwards 2021, Edwards 2022 (a), Edwards 2022 (b), Hoelen 2023, Peltola 2014, Rubenstein 2020, Tram 2022, Weiner 2020, and Weiss 2019) observed how factors contributing to economic well-being affect outcomes in osteoarthritis of the hip (OAH) patients who underwent total hip arthroplasty (THA). The results show that higher income, greater amounts of financial liquid assets, and elevated socioeconomic status contribute to significantly lower rates of mortality, readmission, length of stay, revision surgery, infection, fracture, and dislocation. These factors also significantly improve VAS Pain, WOMAC, and Oxford Hip Scores.

Eleven articles (Cnudde 2017, Edwards 2021, Edwards 2022 (a), Edwards 2022 (b), Goodman 2018, Judge 2011, Leichtenberg 2016, MacKay 2017, Rubenstein 2020, Weiner 2020, and Weiss 2019) investigated the impact of education levels on outcomes in OAH patients who underwent THA. Mortality and readmission rates were significantly reduced in patients with higher education levels. Those with a college-level education demonstrated improved WOMAC Total scores.

Five articles (Cnudde 2017, Tram 2022, Weiner 2020, Weiss 2019, and Yang 2022) examined hospital-related factors, including the hospital's type, bed size, and volume, and their correlation with outcomes for OAH patients who underwent THA. Weiner (2020) concluded that hospitals with low patient volumes exhibit significantly reduced length of stay and discharge times. Tram (2022) and Yang (2022) observed that hospitals with smaller bed sizes experienced significant reductions in readmission rates and hospital-acquired pressure ulcers.

Cnudde (2017), Tram (2022), and Weiss (2019), however, reported mixed findings. They found that county and private hospitals demonstrate significantly improved survival rates compared to university hospitals, government hospitals exhibit significantly lower readmission rates than for-profit hospitals, and private and university hospitals experience significantly lower mortality rates than county hospitals.

Seven articles (Benes 2023, Goodman 2018, Koressel 2022, Sirignano 2023, Tram 2023, Weiner 2020, and Yang 2022) investigated the effects of insurance type on patient outcomes. Koressel (2022) showed that patients on Medicaid had significantly lower length of hospital stay and significantly higher rates of home discharge when compared to patients with dual eligibility. Goodman (2018), Koressel (2022), and Tram (2022) showed that patients on Medicare have significantly better outcomes in WOMAC Pain and Function, significantly increased rates of home discharge, and significantly reduced rates of return to emergency department/readmission when compared to patients with dual eligibility, patients on Medicaid, and patients with private insurance. Weiner (2020) showed that patients with other forms of insurance had a significantly lower hospital length of stay and significantly higher rates of non-home discharge when compared to Medicaid/uninsured patients. Benes (2023) showed significantly lower rates of revision in private insurance patients when compared with public insurance patients.

Sirigano (2023) and Yang (2022) conversely reported that outcomes in dislocation, revision, and hospital acquired pressure ulcers were significantly lower in patients with private insurance, and those without Medicare, when compared to patients with Medicare.

Seven articles (Benes 2023, Goodman 2018, Koressel 2022, Sirignano 2023, Tram 2023, Weiner 2020, and Yang 2022) delved into the impact of insurance type on patient outcomes. Koressel (2022) revealed that patients on Medicaid experienced significantly shorter hospital stays and higher rates of home discharge compared to patients with dual eligibility. Goodman (2018), Koressel (2022), and Tram (2022) demonstrated that patients on Medicare exhibited significantly improved WOMAC Pain and Function scores, higher rates of home discharge, and reduced rates of emergency department visits and readmissions in comparison to patients with dual eligibility, patients insured with Medicaid, and those with private insurance. Weiner (2020) showed that patients with other forms of insurance had significantly shorter hospital stays and increased rates of non-home discharge when compared with Medicaid/uninsured patients. Benes (2023) observed significantly lower revision rates in patients with private insurance when compared to those with public insurance.

However, Sirignano (2023) and Yang (2022) showed that patients with private insurance and those without Medicare experienced significantly fewer cases of dislocation, revision, and hospital-acquired pressure ulcers when compared to patients with Medicare.

Seven articles (Broggi 2022, Delanois 2022, Edwards 2021, Edwards 2022 (a), Edwards 2022 (b), Tram 2022, and Weiss 2019) investigated how living conditions influence the outcomes of patients with OAH who underwent THA. Edwards (2021) and Edwards (2022b) observed that patients who were cohabiting exhibited significantly reduced rates of revision, infection, pneumonia, fracture, dislocation, and mortality in comparison to those who were not cohabiting. Delanois (2022) demonstrated that costs of care were significantly lower in regions without food deserts than in those with food deserts. Broggi (2022) indicated that rates of dislocation, periprosthetic joint infection, readmission, and extended length of stay were significantly lower among urban patients when compared to rural patients.

Conversely, Tram (2022) showed significantly lower rates of readmission among rural patients compared to non-rural patients. Weiss (2019) also indicated significantly lower rates of mortality and readmission in patients who were not cohabiting, in comparison to those who were cohabiting.
Three articles (Brembo 2017, Delanois 2022, and Rubenstein 2020) observed how social support influences the outcomes of patients with OAH who underwent THA. Brembo (2017) found that patients who had perceived social support, reliable alliances, reassurances of worth, and self-efficacy had significantly higher WOMAC Total scores when compared to patients without those factors.

Benefits/Harms of Implementation
Reducing the negative impact of social determinants of health on outcomes of total hip arthroplasty is an important societal goal without significant risk of harm.

Outcome Importance
Low quality studies suggest that social determinants of health impact outcomes after total hip arthroplasty. Given the frequency of negative social determinants of health and the impact on equity, this is an area of high importance.

Cost Effectiveness/Resource Utilization
Social determinants of health may significantly impact cost of care and resource utilization through variation in length of stay, and complication rates and increased post-discharge resource needs.

Acceptability
This option should be widely accepted as it does not lead to a major change in practice.

Feasibility
While there are no specific consistent recommendations to limit the negative impact of social determinants of health in the literature reviewed, it will likely require significant societal and governmental commitment including improved pre-operative health status, structural changes in post-discharge service availability and increased financial resources to improve outcomes.

Future Research
Higher quality research is necessary focusing on the impact of specific societal determinants of health on total hip arthroplasty outcomes. In addition, research on identified, innovative measures to reduce the negative impact of social determinants of health would be valuable.