Commentary

Be honest, kind in discussion of social determinants of health

Social determinants of health are environmental factors that can be modified to improve a patient’s ability to manage musculoskeletal disease and intervention. Where a person lives, works and accesses health care can affect outcomes of surgical care. While many environmental factors are quickly glossed over in preoperative assessments, often with the thought that not much can be done to change them, overall outcomes can be affected, thus leading to conclusions that costly interventions are not valuable to patients and overall population health.

Anthony A. Romeo

Few orthopedic surgeons let these factors stand in the way of surgical intervention when the indications are clear from a musculoskeletal assessment alone. However, evidence is building that we must include socioeconomic and general health status metrics in our consultations for recommending surgery.

Nutritional status

We can have an immediate effect on the assessment of patients’ perioperative nutritional status. While many orthopedic surgeons may feel confident that our preoperative assessment is an effective screening tool, more sophisticated approaches show we have not paid proper attention to objective measures of nutrition.

In 1991, Green and colleagues studied the preoperative nutritional status of patients undergoing total joint arthroplasty. Patients with wound complications had low lymphocyte counts and albumin levels, which further decreased after surgery and did not return to baseline 10 days after surgery. The threshold of a preoperative lymphocyte count of less than 1,500 cells/mm3 increased the chance of developing a wound complication by 5, and an albumin level of less than 3.5 g/dL increased the chance by 7. Today, recommendations to test these serologic levels, along with serum transferrin (negative threshold set at less than 200 mg/dL), are more routine for larger procedures, such as lower extremity joint replacement, but less known for smaller joint procedures and sports medicine.

More work needs to be done in assessing borderline nutritional deficiencies combined with other factors, such as diabetes, smoking, obesity and other social determinants of health, which will adversely affect results and increase complications and liability in patient care. Patients may find fault with the care they received with the perception the surgeon failed to provide the best care. However, patients may also have multiple social determinants of poor health and evidence of malnutrition, which is often excluded from the conversation.

Honest and transparent

Our responsibility in the shared decision-making process is to be transparent, honest and kind in the preoperative discussion. We should include recognized objective assessments of the social determinants of health, including nutritional status. Serology testing should include albumin levels, total lymphocyte count and transferrin levels based on the evidence available.

When levels reflect malnutrition, elective surgical procedures should be avoided, and nutritional consultation pursued. Further evidence indicates morbid obesity, smoking, uncontrolled diabetes and malnutrition are predictors of adverse outcomes. We need to be thoughtful and thorough in discussions of perioperative risk factors, nutritional support and supplements and counseling to mitigate these factors in before, during and after we provide the best orthopedic care possible.

Disclosure: Romeo reports he receives royalties, is on the speakers bureau, is a consultant and does contracted research for Arthrex; receives institutional grants from MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Wright Medical.

Social determinants of health are environmental factors that can be modified to improve a patient’s ability to manage musculoskeletal disease and intervention. Where a person lives, works and accesses health care can affect outcomes of surgical care. While many environmental factors are quickly glossed over in preoperative assessments, often with the thought that not much can be done to change them, overall outcomes can be affected, thus leading to conclusions that costly interventions are not valuable to patients and overall population health.

Anthony A. Romeo

Few orthopedic surgeons let these factors stand in the way of surgical intervention when the indications are clear from a musculoskeletal assessment alone. However, evidence is building that we must include socioeconomic and general health status metrics in our consultations for recommending surgery.

Nutritional status

We can have an immediate effect on the assessment of patients’ perioperative nutritional status. While many orthopedic surgeons may feel confident that our preoperative assessment is an effective screening tool, more sophisticated approaches show we have not paid proper attention to objective measures of nutrition.

In 1991, Green and colleagues studied the preoperative nutritional status of patients undergoing total joint arthroplasty. Patients with wound complications had low lymphocyte counts and albumin levels, which further decreased after surgery and did not return to baseline 10 days after surgery. The threshold of a preoperative lymphocyte count of less than 1,500 cells/mm3 increased the chance of developing a wound complication by 5, and an albumin level of less than 3.5 g/dL increased the chance by 7. Today, recommendations to test these serologic levels, along with serum transferrin (negative threshold set at less than 200 mg/dL), are more routine for larger procedures, such as lower extremity joint replacement, but less known for smaller joint procedures and sports medicine.

More work needs to be done in assessing borderline nutritional deficiencies combined with other factors, such as diabetes, smoking, obesity and other social determinants of health, which will adversely affect results and increase complications and liability in patient care. Patients may find fault with the care they received with the perception the surgeon failed to provide the best care. However, patients may also have multiple social determinants of poor health and evidence of malnutrition, which is often excluded from the conversation.

Honest and transparent

Our responsibility in the shared decision-making process is to be transparent, honest and kind in the preoperative discussion. We should include recognized objective assessments of the social determinants of health, including nutritional status. Serology testing should include albumin levels, total lymphocyte count and transferrin levels based on the evidence available.

When levels reflect malnutrition, elective surgical procedures should be avoided, and nutritional consultation pursued. Further evidence indicates morbid obesity, smoking, uncontrolled diabetes and malnutrition are predictors of adverse outcomes. We need to be thoughtful and thorough in discussions of perioperative risk factors, nutritional support and supplements and counseling to mitigate these factors in before, during and after we provide the best orthopedic care possible.

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Disclosure: Romeo reports he receives royalties, is on the speakers bureau, is a consultant and does contracted research for Arthrex; receives institutional grants from MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Wright Medical.