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The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

Published:September 15, 2018DOI:https://doi.org/10.1016/j.jhsa.2018.06.119

      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.
      • Chen E.
      • Paterson L.Q.
      Neighborhood, family, and subjective socioeconomic status: how do they relate to adolescent health?.
      • Chin-Lun Hung G.
      • Hahn J.
      • Alamiri B.
      • et al.
      Socioeconomic disadvantage and neural development from infancy through early childhood.
      • Non A.L.
      • Roman J.C.
      • Gross C.L.
      • et al.
      Early childhood social disadvantage is associated with poor health behaviours in adulthood.
      • Goodman E.
      • Huang B.
      Socioeconomic status, depressive symptoms, and adolescent substance use.
      • Handley E.D.
      • Rogosch F.A.
      • Guild D.J.
      • Cicchetti D.
      Neighborhood disadvantage and adolescent substance use disorder: the moderating role of maltreatment.
      • Everson S.A.
      • Maty S.C.
      • Lynch J.W.
      • Kaplan G.A.
      Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes.
      • Singh G.K.
      • Kogan M.D.
      Widening socioeconomic disparities in US childhood mortality, 1969 2000.
      • Elgar F.J.
      • Pfortner T.K.
      • Moor I.
      • et al.
      Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study.
      • Powell-Wiley T.M.
      • Ayers C.
      • Agyemang P.
      • et al.
      Neighborhood-level socioeconomic deprivation predicts weight gain in a multi-ethnic population: longitudinal data from the Dallas Heart Study.
      In addition, lower socioeconomic status in childhood has been correlated with an increased risk of developing depression as an adult.
      • Gilman S.E.
      • Kawachi I.
      • Fitzmaurice G.M.
      • Buka S.L.
      Socioeconomic status in childhood and the lifetime risk of major depression.
      Socioeconomic status is acknowledged to influence both the occurrence of and the treatment outcomes for musculoskeletal conditions.
      • Horton T.C.
      • Dias J.J.
      • Burke F.D.
      Social deprivation and hand injury.
      • Court-Brown C.M.
      • Aitken S.A.
      • Duckworth A.D.
      • Clement N.D.
      • McQueen M.M.
      The relationship between social deprivation and the incidence of adult fractures.
      • Menon M.R.
      • Walker J.L.
      • Court-Brown C.M.
      The epidemiology of fractures in adolescents with reference to social deprivation.
      • Ramaesh R.
      • Clement N.D.
      • Rennie L.
      • Court-Brown C.
      • Gaston M.S.
      Social deprivation as a risk factor for fractures in childhood.
      • Pillai A.
      • Atiya S.
      • Costigan P.S.
      The incidence of Perthes' disease in Southwest Scotland.
      • Broderick J.E.
      • DeWitt E.M.
      • Rothrock N.
      • Crane P.K.
      • Forrest C.B.
      Advances in Patient-Reported Outcomes: the NIH PROMIS® measures.
      • Quinn H.
      • Thissen D.
      • Liu Y.
      • et al.
      Using item response theory to enrich and expand the PROMIS® pediatric self report banks.
      • Irwin D.E.
      • Gross H.E.
      • Stucky B.D.
      • et al.
      Development of six PROMIS pediatrics proxy-report item banks.
      Increased social deprivation has been associated with increased risk for hand injuries and upper extremity fractures.
      • Horton T.C.
      • Dias J.J.
      • Burke F.D.
      Social deprivation and hand injury.
      • Court-Brown C.M.
      • Aitken S.A.
      • Duckworth A.D.
      • Clement N.D.
      • McQueen M.M.
      The relationship between social deprivation and the incidence of adult fractures.
      • Menon M.R.
      • Walker J.L.
      • Court-Brown C.M.
      The epidemiology of fractures in adolescents with reference to social deprivation.
      • Ramaesh R.
      • Clement N.D.
      • Rennie L.
      • Court-Brown C.
      • Gaston M.S.
      Social deprivation as a risk factor for fractures in childhood.
      In children, lower socioeconomic status has been associated with increased incidence of Perthes disease.
      • Pillai A.
      • Atiya S.
      • Costigan P.S.
      The incidence of Perthes' disease in Southwest Scotland.
      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.
      • Broderick J.E.
      • DeWitt E.M.
      • Rothrock N.
      • Crane P.K.
      • Forrest C.B.
      Advances in Patient-Reported Outcomes: the NIH PROMIS® measures.
      • Quinn H.
      • Thissen D.
      • Liu Y.
      • et al.
      Using item response theory to enrich and expand the PROMIS® pediatric self report banks.
      • Irwin D.E.
      • Gross H.E.
      • Stucky B.D.
      • et al.
      Development of six PROMIS pediatrics proxy-report item banks.
      • Cunningham N.R.
      • Kashikar-Zuck S.
      • Mara C.
      • et al.
      Development and validation of the self-reported PROMIS pediatric pain behavior item bank and short form scale.
      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.
      • Varni J.W.
      • Thissen D.
      • Stucky B.D.
      • et al.
      PROMIS® Parent Proxy Report Scales for children ages 5–7 years: an item response theory analysis of differential item functioning across age groups.
      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.
      • Bevans M.
      • Ross A.
      • Cella D.
      Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life.
      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.
      • Stone A.A.
      • Broderick J.E.
      • Junghaenel D.U.
      • Schneider S.
      • Schwartz J.E.
      PROMIS fatigue, pain intensity, pain interference, pain behavior, physical function, depression, anxiety, and anger scales demonstrate ecological validity.
      • Hung M.
      • Franklin J.D.
      • Hon S.D.
      • et al.
      Time for a paradigm shift with computerized adaptive testing of general physical function outcomes measurements.
      • Tyser A.R.
      • Beckmann J.
      • Franklin J.D.
      • et al.
      Evaluation of the PROMIS physical function computer adaptive test in the upper extremity.
      • Bartlett S.J.
      • Orbai A.M.
      • Duncan T.
      • et al.
      Reliability and validity of selected PROMIS measures in people with rheumatoid arthritis.
      • Papuga M.O.
      • Mesfin A.
      • Molinari R.
      • Rubery P.T.
      Correlation of PROMIS Physical Function and Pain CAT instruments with Oswestry Disability Index and Neck Disability Index in spine patients.
      • Beckmann J.T.
      • Hung M.
      • Bounsanga J.
      • et al.
      Psychometric evaluation of the PROMIS Physical Function Computerized Adaptive Test in comparison to the American Shoulder and Elbow Surgeons score and Simple Shoulder Test in patients with rotator cuff disease.
      • Beckmann J.T.
      • Hung M.
      • Voss M.W.
      • et al.
      Evaluation of the Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test.
      • Cella D.
      • Riley W.
      • Stone A.
      • et al.
      The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008.
      In addition, the PROMIS CATs have strongly correlated with multiple orthopedic legacy measures of pain and function with favorable floor and ceiling effects.
      • Hung M.
      • Franklin J.D.
      • Hon S.D.
      • et al.
      Time for a paradigm shift with computerized adaptive testing of general physical function outcomes measurements.
      • Tyser A.R.
      • Beckmann J.
      • Franklin J.D.
      • et al.
      Evaluation of the PROMIS physical function computer adaptive test in the upper extremity.
      • Papuga M.O.
      • Mesfin A.
      • Molinari R.
      • Rubery P.T.
      Correlation of PROMIS Physical Function and Pain CAT instruments with Oswestry Disability Index and Neck Disability Index in spine patients.

      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.
      • Singh G.K.
      Area deprivation and widening inequalities in US mortality, 1969–1998.
      • Kind A.J.
      • Jencks S.
      • Brock J.
      • et al.
      Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.
      • Carstairs V.
      • Morris R.
      Deprivation: explaining differences in mortality between Scotland and England and Wales.
      • Salmond C.
      • Crampton P.
      • Sutton F.
      NZDep91: A New Zealand index of deprivation.
      Singh
      • Singh G.K.
      Area deprivation and widening inequalities in US mortality, 1969–1998.
      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.
      • Kind A.J.
      • Jencks S.
      • Brock J.
      • et al.
      Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.
      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.
      • Singh G.K.
      Area deprivation and widening inequalities in US mortality, 1969–1998.

      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.
      • Singh G.K.
      • Kogan M.D.
      Widening socioeconomic disparities in US childhood mortality, 1969 2000.
      • Singh G.K.
      Area deprivation and widening inequalities in US mortality, 1969–1998.
      • Kind A.J.
      • Jencks S.
      • Brock J.
      • et al.
      Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.
      • Dy C.J.
      • Lane J.M.
      • Pan T.J.
      • Parks M.L.
      • Lyman S.
      Racial and socioeconomic disparities in hip fracture care.
      • Jenkins P.J.
      • Watts A.C.
      • Duckworth A.D.
      • McEachan J.E.
      Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome.
      • Barnard J.
      • Grant S.W.
      • Hickey G.L.
      • Bridgewater B.
      Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry.
      • Chen R.
      • Crichton S.
      • McKevitt C.
      • et al.
      Association between socioeconomic deprivation and functional impairment after stroke: the South London Stroke Register.
      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.
      • Thissen D.
      • Liu Y.
      • Magnus B.
      • et al.
      Estimating minimally important difference (MID) in PROMIS pediatric measures using the scale-judgment method.
      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,
      • Yost K.J.
      • Eton D.T.
      • Garcia S.F.
      • Cella D.
      Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
      • Amtmann D.
      • Kim J.
      • Chung H.
      • et al.
      Minimally important differences for Patient Reported Outcomes Measurement Information System pain interference for individuals with back pain.
      • Lee A.C.
      • Driban J.B.
      • Price L.L.
      • et al.
      Responsiveness and minimally important differences for 4 Patient-Reported Outcomes Measurement Information System Short Forms: Physical Function, Pain Interference, Depression, and Anxiety in knee osteoarthritis.
      • Swanholm E.
      • McDonald W.
      • Makris U.
      • Noe C.
      • Gatchel R.
      Estimates of minimally important differences (MIDs) for two Patient-Reported Outcomes Measurement Information System (PROMIS) Computer-Adaptive Tests in chronic pain patients.
      Thissen et al
      • Thissen D.
      • Liu Y.
      • Magnus B.
      • et al.
      Estimating minimally important difference (MID) in PROMIS pediatric measures using the scale-judgment method.
      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
      CharacteristicQuartile 1

      Least Deprived
      Quartile 2Quartile 3Quartile 4

      Most Deprived
      Age (y), mean (SD)12.2 (2)12.1 (3)12 (3)11.7 (2)
      Sex
       Male62%64%68%66%
      Race
       White88%85%73%50%
       Black6%10%24%47%
       Other6%5%3%3%
      Fracture type
       Humerus6%7%7%8%
       Forearm33%41%43%37%
       Wrist/hand59%46%44%51%
       Other2%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 CATQuartile 1Least DeprivedMean (SD)Quartile 2

      Mean (SD)
      Quartile 3

      Mean (SD)
      Quartile 4Most DeprivedMean (SD)
      Upper Extremity Function39 (11)37 (11)36 (10)35 (11)
      Mobility48 (10)47 (9)46 (9)44 (9)
      Pain Interference46 (8)46 (8)48 (8)50 (8)
      Peer Relations55 (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
      • Torsheim T.
      • Nygren J.M.
      • Rasmussen M.
      • et al.
      Social inequalities in self-rated health: a comparative cross-national study among 32,560 Nordic adolescents.
      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 al
      • 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.
      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.
      Previous studies investigating the relationship between social deprivation and outcomes in orthopedic patients have largely focused on adults. Clement et al
      • Clement N.D.
      • Muzammil A.
      • Macdonald D.
      • Howie C.R.
      • Biant L.C.
      Socioeconomic status affects the early outcome of total hip replacement.
      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 al
      • Jenkins P.J.
      • Perry P.R.
      • Yew Ng C.
      • Ballantyne J.A.
      Deprivation influences the functional outcome from total hip arthroplasty.
      reported worse functional scores both before and after surgery in socially deprived patients undergoing total hip arthroplasty. Horton et al
      • Horton T.C.
      • Dias J.J.
      • Burke F.D.
      Social deprivation and hand injury.
      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
      • Ramaesh R.
      • Clement N.D.
      • Rennie L.
      • Court-Brown C.
      • Gaston M.S.
      Social deprivation as a risk factor for fractures in childhood.
      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.
      • Menon M.R.
      • Walker J.L.
      • Court-Brown C.M.
      The epidemiology of fractures in adolescents with reference to social deprivation.
      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.
      • Chen E.
      • Paterson L.Q.
      Neighborhood, family, and subjective socioeconomic status: how do they relate to adolescent health?.
      • Chin-Lun Hung G.
      • Hahn J.
      • Alamiri B.
      • et al.
      Socioeconomic disadvantage and neural development from infancy through early childhood.
      • Non A.L.
      • Roman J.C.
      • Gross C.L.
      • et al.
      Early childhood social disadvantage is associated with poor health behaviours in adulthood.
      • Goodman E.
      • Huang B.
      Socioeconomic status, depressive symptoms, and adolescent substance use.
      • Handley E.D.
      • Rogosch F.A.
      • Guild D.J.
      • Cicchetti D.
      Neighborhood disadvantage and adolescent substance use disorder: the moderating role of maltreatment.
      • Everson S.A.
      • Maty S.C.
      • Lynch J.W.
      • Kaplan G.A.
      Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes.
      • Singh G.K.
      • Kogan M.D.
      Widening socioeconomic disparities in US childhood mortality, 1969 2000.
      • Elgar F.J.
      • Pfortner T.K.
      • Moor I.
      • et al.
      Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study.
      • Powell-Wiley T.M.
      • Ayers C.
      • Agyemang P.
      • et al.
      Neighborhood-level socioeconomic deprivation predicts weight gain in a multi-ethnic population: longitudinal data from the Dallas Heart Study.
      • Ramaesh R.
      • Clement N.D.
      • Rennie L.
      • Court-Brown C.
      • Gaston M.S.
      Social deprivation as a risk factor for fractures in childhood.
      • Pillai A.
      • Atiya S.
      • Costigan P.S.
      The incidence of Perthes' disease in Southwest Scotland.
      • Irwin D.E.
      • Gross H.E.
      • Stucky B.D.
      • et al.
      Development of six PROMIS pediatrics proxy-report item banks.
      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.

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