Social Determinants of Delay: Commentary on an article by Lacey M. Smith, MSc, et al.: "Public Insurance and Single-Guardian Households Are Associated with Diagnostic Delay in Slipped Capital Femoral Epiphysis".
Commentary Prompt diagnosis is crucial in the treatment of slipped capital femoral epiphysis (SCFE). Delays in diagnosis have been associated with increased slip severity at the time of presentation, which, in turn, carries with it an increased risk of complications such as osteonecrosis and chondrolysis1. In the present study, Smith et al. take us one step closer to understanding the social factors that lead some patients with SCFE to receive prompt diagnosis and treatment and other patients to experience diagnostic delays and inferior outcomes. The authors retrospectively reviewed 351 cases of surgically treated SCFE and found that approximately one-third of patients experienced a delay of ≥12 weeks between the time of symptom onset and the eventual diagnosis of SCFE. In the multivariable analysis, they found that the social factors of public insurance (i.e., Medicaid) (p = 0.03) and a single-guardian household (p = 0.04) were significantly associated with a delay in diagnosis of ≥12 weeks. In the interpretation of these results, 3 points bear mentioning. First, the study did not consider what likely represents the most powerful social determinant of health: socioeconomic status. Because of the limitations of the data set, important factors such as household income and parent educational attainment could not be directly measured. The authors attempted to estimate socioeconomic status via variables such as the Social Vulnerability Index (SVI), a composite measure of neighborhood disadvantage derived from 17 socioeconomic variables. However, this measure (calculated at the Census-tract level) does not always correlate perfectly with individual household socioeconomic status (there are, for example, many orthopaedic surgeons who lived in high-SVI areas while completing their residencies in Boston). Second, there was considerable overlap between the 3 primary predictors examined in this study (public insurance status, family structure, and SVI) as well as race and ethnicity. That is, patients living in areas of high SVI were also more likely to have Medicaid insurance, more likely to be living in single-guardian households, and more likely to be Black or Hispanic. The high levels of overlap between these variables (termed collinearity in statistics) prevented these variables from being adjusted for one another in a multivariable analysis. As a result, it is difficult to know, for example, whether family structure is independently associated with the observed delays in diagnosis, or if this relationship could perhaps be confounded by insurance type. Third, given that the investigation was a retrospective analysis, the study’s findings should be taken to represent association and not necessarily causation. That is, one cannot be certain whether Medicaid insurance itself causes delays in diagnosis (i.e., by making it more difficult to secure an appointment) or whether holding Medicaid insurance is simply a marker of lower socioeconomic status, which has repeatedly been associated with inferior outcomes in orthopaedic surgery2. Although the documentation of differences in treatment and outcome within orthopaedic surgery remains critically important, what is even more crucial at the present time are ideas and interventions to ameliorate the many health-care disparities that have been described over the past several decades3. With regard to the present study, how could the findings be operationalized to facilitate the prompt diagnosis and treatment of those patients found to be at risk for delay? Although orthopaedic surgeons (and physicians generally) focus most of their attention on the medical and surgical treatment of disease, recent research has estimated that 80% to 90% of health outcomes in our country actually result from social determinants of health (with clinical care accounting for only 10% to 20%)4. What might our health-care system look like if this fact were more widely appreciated and acted upon? In the case of SCFE, what might our practices look like if we truly sought to eliminate the delays in diagnosis experienced by patients at the lower end of the socioeconomic ladder? If it is actually the case that eliminating such disparities requires creating a “preferential option for the poor,”5 how would we go about creating such an option for our patients?
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