EXECUTIVE SUMMARY

Social determinants of health are the conditions in which people are born, grow, work, and age.

  • Psychological distress can be a social determinant of health that is not as well understood or easy to measure.
  • Before learning more about surgical disparities and their effects on various racial and ethnic groups, researchers will need more data on patients’ social determinants of health.
  • Patient-centered surgery that addresses social determinants of health can be used to optimize surgical outcomes.

One important contributing factor to ongoing racial disparities in surgical care appears to be social determinants of health, although data are limited.

The World Health Organization defines social determinants of health this way: “The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.”1

“Our national surgical databases do not commonly collect information on social determinants of health,” says Mohamad J. Halawi, MD, associate professor and chief quality officer for musculoskeletal services at Baylor College of Medicine. “If we are to have a truly significant or meaningful root cause analysis, we need much more comprehensive data. We currently live in a system that looks primarily at organic causes of disparities, and that is a shortcoming based on our research.”

In a recent study on racial differences in pain and function after knee arthroplasty, investigators’ analysis accounted for social determinants of health, using more of these data than had been used in prior analyses.2

“We found that if you account for these different social determinants of health, these are factors that feed into having more severe pain or functional loss prior to surgery,” says Daniel L. Riddle, PT, PhD, FAPTA, professor in the departments of physical therapy, orthopedic surgery, and rheumatology at Virginia Commonwealth University in Richmond. “For example, patients who are African American tend to have higher levels of pain catastrophizing, higher levels of depressive symptoms, lower income, and lower education.”

Riddle and colleagues also found African American patients tend to underuse knee arthroplasty, waiting until the condition was more severe before they sought treatment.

“When we accounted for all these factors in our comparisons, the difference became very small and, clinically, probably not relevant,” Riddle says. “When social determinants of health are accounted for, the differences in not only baseline preoperative pain and function, but also improvements in pain and function over time, are substantially reduced.”

Disparities in surgical and health outcomes go beyond the color of a patient’s skin. Psychological distress can be a social determinant of health, too.

“One of the psychological health constructs is pain catastrophizing. It’s related to having a difficult time coping with pain,” Riddle explains. “Because of social inequities that have been in our society for decades and centuries, psychological distress levels tend to be higher for African Americans.”

When people engage in pain catastrophizing, they tend to ruminate about their pain, thinking about it often. Those who do this tend to experience persistent pain. “In our study, pain catastrophizing varies, depending on how much pain a person has,” Riddle says. “If you can reduce pain, catastrophizing also will [disappear].”

African American surgery patients tend to experience more pain and for longer periods because they often delay treatment. They also tend to deal with more life stressors. “If you are under constant stress, live in a stressful neighborhood, have challenges to putting food on the table, and the stress of racism, then it all adds up,” Riddle says.

In addition to measuring and assessing social determinants of health, surgeons can help reduce disparities by adopting a philosophy of patient-centered surgery, Halawi suggests. “You learn about the whole patient and treat them as a whole,” he says. This includes looking at the patient’s individual needs, support system, expectations, and overall health.

“Surgeons need to understand where patients are coming from and what their needs and limitations are,” Halawi says. “Do whatever you can to tailor the surgery to the patient and to make sure they’re well-informed.”

Patient-centered surgery includes patient preparation to optimize outcomes. Take into account these actions:

  • Modulate modifiable risk factors (e.g., smoking cessation);
  • Optimize any of the patient’s medical issues;
  • Team with patients and their caregivers so everyone is on the same page;
  • Bridge any language or cultural barriers;
  • Ensure the patient understands what to expect from the surgery, but also respect the patient’s cultural beliefs.

“Many factors, including social, cultural, and economic, likely play a big role in why we have health disparities,” Halawi says. “It’s only when we have more robust and comprehensive data that we can have more effective discussion toward the resolution of this problem.”

REFERENCES

  1. World Health Organization. What are the social determinants of health?
  2. Riddle DL, Slover J, Keefe FJ, et al. Racial differences in pain and function following knee arthroplasty: A secondary analysis from a multicenter randomized clinical trial. Arthritis Care Res (Hoboken) 2020; Mar 7:10.1002/acr.24177. doi: 10.1002/acr.24177. [Online ahead of print].