Purpose
Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures.
Methods
This cross-sectional evaluation analyzed data from 975 new pediatric patients (8–17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population.
Results
A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles.
Conclusions
Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults.
Type of study/level of evidence
Prognostic II.
Key words
Social, mental, and physical health are interrelated, with each facet of health influencing the others. Lower socioeconomic status has been associated with obesity, negative psychological characteristics, substance abuse, depression, diabetes, childhood mortality, and physical and psychological symptoms in children.
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In addition, lower socioeconomic status in childhood has been correlated with an increased risk of developing depression as an adult.10
Socioeconomic status is acknowledged to influence both the occurrence of and the treatment outcomes for musculoskeletal conditions.
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Increased social deprivation has been associated with increased risk for hand injuries and upper extremity fractures.11
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In children, lower socioeconomic status has been associated with increased incidence of Perthes disease.15
However, the relationship between socioeconomic status and patient-reported outcomes in pediatric upper extremity surgical practice is unclear.The National Institutes of Health developed the Patient-Reported Outcomes Measurement Information System (PROMIS) to allow for standardized measurement of patient-reported outcomes and health-related quality of life. Pediatric PROMIS assessments have multiple social, mental, and physical health domains including Peer and Family Relationships, Emotional Stress, Fatigue, Pain Interference, Mobility, and Upper Extremity Function.
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The questionnaire may be administered in a computerized adaptive testing (CAT) format and is validated for self-administration for patients 8 to 17 years old.20
Although social deprivation is acknowledged to influence physical and mental health in adults, it is less clear if social deprivation influences perceived health in children. The primary aim of this study was to evaluate the association between social deprivation and PROMIS scores in pediatric patients with upper extremity fractures. This tested the null hypothesis that there would be no difference in PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relationship assessments among patients with more social deprivation than among those with less social deprivation.
Materials and Methods
Approval for this study was obtained from our institutional review board. All records were evaluated with a waiver of written consent. This cross-sectional evaluation analyzed data from 1,181 pediatric patients who had presented to a tertiary orthopedic center with upper extremity fractures between June 1, 2016, and June 1, 2017. All new clinic patients 8 to 17 years old with upper extremity fractures were eligible for inclusion. Patients were identified using International Classification of Diseases, 10th Revision, codes: Humeral Shaft (S42.2, S42.3), Distal Humerus (S42.4), Proximal Forearm (S52.0, S52.1, S52.2, S52.3), Distal Forearm (S52.5, S52.6), Unspecified Forearm (S52.9), and Wrist/Hand (S62.0, S62.1, S62.2, S62.3, S62.5, S62.6, S62.9). Patients were excluded if PROMIS scores were incomplete or absent (n = 136).
PROMIS scores
All patients presenting to our institution’s orthopedic pediatric clinics were provided a computer tablet (iPad mini; Apple, Cupertino, CA) at check-in preloaded with PROMIS Pediatric Upper Extremity Function, Mobility, Pain Interference, and Peer Relations CATs. The PROMIS scores were generated and uploaded into the patients’ electronic health record upon module completion. The PROMIS CATs are normalized such that a score of 50 represents the normative population mean with an SD of 10.
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A higher score represents a higher level of a given metric such that a higher Physical Function score indicates better function, whereas a higher Pain Interference score indicates more pain. The PROMIS has been validated in many patient populations, including a variety of orthopedic populations.22
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In addition, the PROMIS CATs have strongly correlated with multiple orthopedic legacy measures of pain and function with favorable floor and ceiling effects.23
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Measuring social deprivation
The Area Deprivation Index (ADI) quantified the social deprivation of each patient community according to 9-digit home zip code. The ADI is a validated measure of social deprivation that accounts for 17 U.S. Census measures across the domains of poverty, education, housing, and employment, which mirror those used in other countries to measure social deprivation.
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Singh30
found a reliability coefficient of 0.95 for the ADI, indicating a high degree of consistency, and demonstrated expected correlations between the ADI and known mortality measures to confirm validity. The ADI of each geographical area is determined by the sum of each included socioeconomic factor multiplied by its predetermined factor coefficient. After standardization, index values range from –53 to 129, with increasing values indicating increasing levels of social deprivation: a patient whose zip code translates to an ADI of 100 is from a more deprived area than someone with an ADI of 30. Socioeconomic disadvantage is a complex entity that indicates a combination of low income, limited education, poor living conditions, and decreased social support.31
Therefore, as opposed to using a single socioeconomic proxy such as insurer or annual income, using a composite index such as ADI, which encompasses multiple domains of disadvantage, is a robust method for assessing social disadvantage.30
Statistical analysis
We categorized patients according to established ADI score break-points defining national quartiles to allow for direct comparison between the most and the least deprived groups of individuals, which is consistent with prior investigations of social deprivation.
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Student t tests and chi-square analysis assessed differences in patient age, sex, race, and fracture type between patients according to ADI quartile. Using the national ADI file, scores of –53.037 to 94.76100 capture the least deprived quartile, followed by 94.76101 to 104.72400, 104.72401 to 110.97000, and 110.97001 to 128.979 defining the most deprived quartile.Bivariate testing with Student t tests compared mean PROMIS scores between individuals in the most and least deprived quartiles of the population based on ADI score. An estimated minimal clinically important difference (MCID) of 3 points on PROMIS assessments was used as a proxy for clinically relevant between-group differences based on work by Thissen et al.
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Although previous literature attempting to define MCID values for PROMIS short forms and CATs in various populations has estimated an MCID of 3 to 5 in various populations,39
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Thissen et al38
established an MCID of 2 to 3 for pediatric self-report PROMIS measures based on scale-judgment analysis by a combination of adolescents, parents, and clinicians. Therefore, we utilized an MCID of 3 as a proxy for clinically relevant between-group differences for this study of children completing self-report PROMIS measures.An a priori sample size calculation was used to determine the necessary date range for study data collection. To perform a Student t test of our primary outcome (PROMIS score) between the most and the least deprived groups, 234 patients were needed in each group to provide 90% power to detect a minimally relevant difference (3 points) on a PROMIS domain assuming an SD of 10 with statistical significance defined at P less than .05. Based on the distribution of ADI scores in patients in other studies from our institution, we requested 1 year of data pulled and then confirmed that these provided sufficient sample size.
Results
A total of 1,081 patients were identified for inclusion in the study, and 96 were excluded owing to having incomplete or absent PROMIS data and 10 were excluded for lack of a valid home zip code for ADI scoring. Of the 975 patients included, 327 (34%) lived in areas categorized as the most socially deprived national quartile of the United States, and 202 (21%) resided within the least socially deprived national quartile. Racial composition between the 2 groups differed significantly, with 88% of patients in the least deprived quartile being white and 47% of patients in the most deprived quartile being black. The majority of patients were male, and fractures of the wrist/hand predominated. There was no clinically relevant difference in age, patient sex, or fracture types between the 2 groups (Table 1).
Table 1Demographic Data According to Social Deprivation Group
| Characteristic | Quartile 1 Least Deprived | Quartile 2 | Quartile 3 | Quartile 4 Most Deprived |
|---|---|---|---|---|
| Age (y), mean (SD) | 12.2 (2) | 12.1 (3) | 12 (3) | 11.7 (2) |
| Sex | ||||
| Male | 62% | 64% | 68% | 66% |
| Race | ||||
| White | 88% | 85% | 73% | 50% |
| Black | 6% | 10% | 24% | 47% |
| Other | 6% | 5% | 3% | 3% |
| Fracture type | ||||
| Humerus | 6% | 7% | 7% | 8% |
| Forearm | 33% | 41% | 43% | 37% |
| Wrist/hand | 59% | 46% | 44% | 51% |
| Other | 2% | 6% | 5% | 4% |
Increasing social deprivation also demonstrated a consistent dose response as mean PROMIS scores gradually worsened in each quartile (Table 2). Children living in the most socially deprived quartile had significantly worse Upper Extremity Function, Mobility, Peer Relationships, and greater Pain Interference than those living in the least deprived quartile (P < .05) (Table 2). The magnitude of this effect approximated that presumed to be an MCID indicating a small but relevant difference.
Table 2Mean PROMIS Scores According to Social Deprivation Group
| PROMIS CAT | Quartile 1Least DeprivedMean (SD) | Quartile 2 Mean (SD) | Quartile 3 Mean (SD) | Quartile 4Most DeprivedMean (SD) |
|---|---|---|---|---|
| Upper Extremity Function | 39 (11) | 37 (11) | 36 (10) | 35 (11) |
| Mobility | 48 (10) | 47 (9) | 46 (9) | 44 (9) |
| Pain Interference | 46 (8) | 46 (8) | 48 (8) | 50 (8) |
| Peer Relations | 55 (10) | 53 (10) | 52 (9) | 50 (9) |
Discussion
This study evaluated the association of social deprivation with patient-reported outcomes measures in children with upper extremity fractures. Our data indicate that children in the most socially deprived national quartile had worse PROMIS scores in the Upper Extremity Function, Mobility, Pain Interference, and Peer Relationship domains than children in the least socially deprived national quartile. These findings corroborate results of 2 prior studies from outside of the United States. Torsheim et al
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found a 2- to 4-fold increased risk of self-reported fair or poor health among 32,560 European adolescents (11–15 years old) when contrasting those individuals from low family affluence/wealth with those from high socioeconomic levels. Verstappen et al44
had similar findings in a cohort of 923 children with juvenile idiopathic arthritis in the United Kingdom. In that nearly exclusively white population, socioeconomic status was categorized as high, middle, or low. Between the socioeconomic groups, there was no significant difference in physician-reported disease activity arthritis measures, age at onset, sex, or delay to first rheumatological visit. However, the low socioeconomic group reported worse Childhood Health Assessment Questionnaire scores, more pain, and worse expectations regarding their chance for improvement with treatment. Those authors argued for increased utilization of multidisciplinary teams to provide social, psychological, and educational resources to this at-risk group. Similarly, when considering patient demographic data and broad injury characteristics, we found no difference in patient age, sex, or fracture-type distribution associated with social deprivation. Despite study populations from different countries and distinct diagnoses (ie, school-aged volunteers, juvenile idiopathic arthritis, upper extremity fracture), these studies indicate a consistent association between increased social deprivation and worse perceived health.- Verstappen S.M.
- Cobb J.
- Foster H.E.
- et al.
The association between low socioeconomic status with high physical limitations and low illness self-perception in patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study.
Arthritis Care Res (Hoboken). 2015; 67: 382-389
Previous studies investigating the relationship between social deprivation and outcomes in orthopedic patients have largely focused on adults. Clement et al
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found less affluent total hip arthroplasty patients had increased symptom severity at presentation, less patient satisfaction, worse postoperative outcomes, and higher risk of dislocation and mortality. Similarly, Jenkins et al46
reported worse functional scores both before and after surgery in socially deprived patients undergoing total hip arthroplasty. Horton et al11
described worse patient-reported outcomes as measured by the Michigan Hand questionnaire and Physical component of the Short Form-12 among socially deprived young and middle-aged hand trauma patients at the time of presentation. Our study focused on reported health at presentation and did not include final outcomes. Further investigation will be required to determine if children with increased social deprivation receive the same treatment benefit. It is possible that children with increased social deprivation start with a lower baseline perceived health and, despite realizing the same improvement from treatment, could end with worse PROMIS scores compared with more affluent patients. Alternatively, social deprivation could influence the actual magnitude of improvement from treatment. These questions will require continued longitudinal investigation.In addition to a relationship between patient-reported outcomes and social deprivation, social deprivation has also been associated with an increased incidence of pediatric upper extremity fractures. Ramaesh et al
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found greater social deprivation significantly correlated with the increased incidence of fractures in 109,109 patients younger than 16 years. They speculated that this was due to more socially deprived areas being those with higher traffic volumes and speeds where children are more likely to walk unsupervised. Another group found socioeconomic factors correlated with increased incidence of upper extremity fractures in a sample of 1,574 patients younger than 17 years.13
Adolescent males living in socially deprived neighborhoods were more likely to sustain fractures of the hand and carpus, whereas females living in similar neighborhoods were more likely to sustain fractures of the proximal upper extremity and distal radius. In our study, we cannot draw conclusions about the incidence of these upper extremity fractures because the chance of patients presenting to our physicians, as opposed to surgeons outside of our group, for fracture care varies based on injury timing, whether or not transport occurred by ambulance, and presumed payer such that socioeconomics may influence treatment occurring at our tertiary center versus private centers in our region.This study has potential limitations. Patients were instructed to complete the PROMIS survey without assistance, but clinical staff did not monitor the patients during survey completion. We acknowledge potential bias if accompanying family member(s) assisted the patient with survey completion. Inherent to our cross-sectional design, we are unable to comment on the association of social deprivation with ultimate outcomes, but our data indicate that patients from highly deprived areas are consistently starting treatment from a state of worse reported health. This study did not account for medical and psychological comorbidities that can influence patient-reported health. In addition, no objective functional outcomes measures or physical examination components were collected to compare with the patient-reported outcomes.
Our data indicate a consistent association between increased social deprivation and worse self-reported health on each of the PROMIS CATs delivered. With a mean patient age of 11 years in this study, it is clear that social deprivation is associated with changes in perceived musculoskeletal health early in life. This finding, although novel in this particular patient population, is consistent with the broader literature reporting that social deprivation and worse socioeconomic status are associated with poorer physical health and mental health.
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Therefore, we believe it is reasonable to support efforts to combat the effects of social deprivation in children as changes in self-reported health are already evident early in life.Supplementary Data
- Data Profile
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Article info
Publication history
Published online: September 15, 2018
Accepted:
June 29,
2018
Received:
May 29,
2018
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2018 by the American Society for Surgery of the Hand. All rights reserved.
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