Understanding SocioEconomic Models can Reduce the Need for Knee Surgery

Osteoarthritis affects approximately 3.9 million Canadians over the age of 20 and can be a major source of pain (GoC, 2020). It can prevent people from being able to perform their normal daily rituals such as physical activity, socialization, and cooking. As the joint degrades and symptoms become unmanageable, patients may start asking about surgical options. Knee replacement surgery, or arthroscopy, is used to treat severe osteoarthritis if outpatient therapy is no longer able to manage the disease and its symptoms (ABJHI, 2019). It is publicly accepted that the “gold standard” for osteoarthritis in the knee is a replacement, however research shows that proper out-patient treatment plans can successfully manage symptoms and prevent major surgery in up to 60% of patients (ABJHI, 2019). Since surgery is not without risk, it is important to understand an individual’s SDoH to develop a proper pain management in an effort to reduce the need for arthroplasty (Bryk et al., 2013; Vennu et al., 2020). Understanding the overlapping concepts of a socio-economic model, and applying that knowledge to patient care programs, can help patients better manage their osteoarthritis symptoms and delay, or even prevent, the need for a major surgery.

The Socio-Economic Method (SEM) looks at multiple levels of influence: Individual, Interpersonal, Organization, Community, and Public Policy (White, F.M.M., 2015). These levels overlap and intersect, implying that they are not stand-alone features but blend together to provide a more clear understanding of the background and social influences a patient is subjected to (White, F.M.M., 2015). The Individual level reflects who the patient is and what they bring with them from a biological and medical standpoint. This includes genetics, age, education, and medical history (CDCP, 2022). The Interpersonal level reflects the relationships between the patient seeking help in managing their OA symptoms and those who can provide that support (CDCP, 2022). This includes family, friends, employers, primary care physicians, surgical teams, and rehabilitation teams. The Organizational level speaks to the physical environment in which a patient receives care. This includes access to modern technology, quality of the facilities, and where the facility is located in relation to the patient and the patient's needs (CDCP, 2022; White, F.M.M., 2015). Access to preventative services such as physiotherapy and occupational therapy can help manage patient's OA symptoms but if those services are not conveniently located, a patient may underutilize them and see disproportionate osteoarthritis degredation. The Community level paints a picture on the support network the patient is a part of that could hinder or facilitate their compliance with preventative measures and their ability to manage their osteoarthritis symptoms (White, F.MM., 2015; CDCP, 2022). Examples include the actual neighbourhood in which a patient lives and the availability of resources, as well as the social communities in which a patient is a member such as veteran's organizations, churches, or councelling services which can boster the resiliance of each patient. Finally, the Public Policy reflects the public policies and legal infrastructure which are in place at a regional, national, and global level which impact a patient's ability to seek care, and the standardized practice they receive (White, F.MM., 2015; CDCP, 2022). This can be quite variable and so patient's management plans and outcomes can be similarly subject to variability. Since surgeries come with great cost to patients and public health care systems alike, using SEM to better support pain management and surgical prevention programs is vital in promoting healthy living with knee osteoarthritis.

This knowledge can be applied to each patient on an individual basis to better support a reasonable, achievable, and egalitarian osteoarthritis pain management plan. This model can also be used to evaluate how osteoarthritis is being managed, which in turn can be a decisive factor in persuing a surgical or non-surgical pathway for patients with progressive osteoarthritis. By interweaving these levels of influence, patients and care teams can work together to promote pain management programs for patients and offset the need for preventable surgeries.

Figure: Social ecological model of factors that affect health outcomes. Adapted from McLeroy et al.

Individual

Candidacy for arthroplasty depends on the condition of the knee and its impact on the patient’s quality of life, age, weight, activities performed, and pre-existing medical conditions (MHA, 2021). Patients who are overweight or have multiple co-existing medical ailments may experience more severe OA symptoms, have more rapid disease progression, and may require surgery than others, however they may not be candidates for surgery depending on their baseline health levels. Managing pain and disease progression is instrumental for these patients and goes beyond weight loss.

In addition to looking at the biological and physical factors of a patient, the individual sphere includes the relationship between caregivers and the patient (White, F.M.M., 2015). This can be classified as either individual or interpersonal, which serves to reinforce how integral and overlapping these spheres of influence can be in patient-centred care. Strong relationships with primary caregivers and medical teams can lead to improved preventative outcomes, but can favour those of high health literacy and high socioeconomic status, or those with strong autonomous capacity.

Interpersonal

Interpersonal factors focus on relationships and support networks which increase or decrease the need for arthroplasty (CDCP, 2022). Patients with strong support networks that assist with reliable transportation, rehabilitation, and healthcare management are less likely to need knee replacement surgery (ABJHI, 2019). It can be as simple as having reliable friends or family members who can help patients get to their appointments and promote regular exercise at home. These networks can also include cooperative employers with good benefits which supports work modifications and flexible scheduling for therapy appointments. Patients who are able to attend pain management therapy sessions regularly are better able to manage their symptoms and maintain satisfactory quality of life and activity levels (MHA, 2021).

The sphere of influence for an individual centers on addressing the unique needs of a single patient, encompassing factors such as genetics, and medical history. (CDCP, 2022; White, F.M.M., 2015). Osteoarthritis pain management requires a multidisciplinary approach, including family physicians, physiotherapists, radiologists for pain management injections, and sports medicine doctors, among others (MHA, 2021; Karches et al., 2023). Some of these resources are not covered by public health insurance and can be cost-prohibitive, resulting in poor symptom management and rapid disease progression, increasing the likelihood of a knee replacement (Bryk et al., 2013).

If a patient still needs surgery, the 12-week post-surgical rehabilitation period is an intense ritual of regular physiotherapy appointments, physician or surgical follow up appointments, access to safe pain medication, and management of household tasks (MHA, 2021). A strong supportive network dictates how well a patient can manage their OA symptoms, and will be a strong indicator in how well they heal from this surgery.

Organization

Organization evaluates the institutional settings in which patients receive care and how they can mitigate the progression of disease (White, F.M.M., 2015). This most often looks at the location in which a patient receives care, as will be discussed in the Community sphere, but from a more transactional approach. For patients seeking knee replacement surgery, where a patient chooses, or is able, to receive care affects wait times for surgery (AHS, 2023; Wylie, W.D. 2021). Excessive wait times for arthroplastic surgery can lead to greater surgical risks and poor outcomes, as the joint riddled with arthritis continues to degrate, becoming more stiff and painful as the bone rubs against bone in the absence of lubricating cartillage. As a result, patients have more and more difficulty managing their symptoms and they can start to disengage from pain management therapies, social activities, and experience a decline in their mental health (Wang & Geng, 2019). These risk factors are linked to poor surgical outcomes for patients with osteoarthritis (Wang & Geng, 2019). In the event that a patient requires arthroplasty, access to timely surgery is critical for the health and well-being of that patient.

To better manage surgical expectations Alberta Health Services (AHS) has evidence-based guidelines for elective surgeries. AHS recommends a 26-week waiting period between the decision to undergo surgery and the actual date of surgery (ABJHI, 2019). The wait times vary based on the city, and even between hospitals within the same city, which can drastically affect equitable access to care. In Grande Prairie patients can wait up to 191.7 weeks while in Calgary that number is closer to 51 weeks (AHS, 20230; AB&J, 2019). Individual and community access to timely surgeries can lead to complications such as severe progression of the disease which may require more expensive surgical treatment. Additionally, prolonged waiting times can result in a lower quality of life for the patient, often impacting their mental health, employment, and fitness levels. These factors can collectively increase surgical risks and lead to poor outcomes (Wang & Geng, 2019).

Community

In addition to individual and relational factors, patients are part of communities which shape their attitudes and access to health services.

Community focuses on the social and environmental settings in which patients receive care such as nursing homes, hospitals, and clinics (White, F.MM., 2015; CDCP, 2022). It seeks to understand osteoarthritis pain management through resources and support mechanisms available at the community level. This can include community-based programs such as nursing home group exercise classes or therapy regimes, public health education campaigns which address preventative therapies,

and general population expectation of treatment. At this level, societal expectations of knee replacement as an inevitability can be addressed, and a new mindset toward preventative measures, where possible, can be encouraged (AHS, 2021). The Government of Canada and the Government of Alberta, along with the Arthritis Society all produce public health promotion and awareness campaigns at the community level through advertisements, publications, and community outreach initiatives.

It is at the community level that it becomes more clear how the different spheres of influence in a SEM model start to influence and play off each other. If a patient has encouraging individual factors with overall good health and fitness level and are able to access regular therapy to manage their symptoms, then they are less likely to experience rapid osteoarthritis disease progression. However arthritis does worsen naturally over time and so having a strong support system and access to surgical consultations to empower patients to make autonomous decisions becomes vital. However, if a patient is surrounded by a community which believes that arthroplasty is inevitable, a patient may. be discouraged from trying a preventative approach, feeling this is sub-standard care or that the onus is incorrectly placed on them and they may become resentful. Alternatively, if a patient's community understands and supports the idea that symptom management is often the best form of treatment, the patient may be more compliant with their therapy regime and be able to prevent a surgical outcome without compromising the quality of life. This also means their community must be flexible and be able to shift around their own adaptive needs as they manage their ever changing osteoarthritis symptoms. Up until now, these levels have been mostly social in nature, but the final sphere offers a much more utilitarian viewpoint.

Public Policy

The widest sphere of influence focuses on global factors or policies which lead to inequal distribution of health outcomes (Karches et al., 2021). For patients experiencing knee pain due to osteoarthritis, this primarily involves an examination of the policies and procedures that affect their ability to navigate healthcare resources successfully, as well as how healthcare practitioners deliver standardized care. Standing x-rays are recommended to diagnose osteoarthritis and track its disease progression to help determine a patient’s surgical candidacy (ABJHI, 2019; Hunter et al., 2015; Messier et al., 2015). MRIs are only recommended if there is suspicion of co-existing pathologies (Anderson & Froese, 2021). They are too costly and time-consuming to be a valuable surveillance tool and the results rarely affect surgical candidacy (Anderson & Froese, 2021; Roemer et al., 2014). Ultrasound is not recommended in the diagnosis, treatment planning, or surgical referral process (Hunter et al., 2015). Despite this, patients are often referred for any combination of one or all three imaging modalities prior to seeing a sports medicine doctor or surgeon (ABJHI, 2019; Wylie, W.D. 2021).

Radiographs of partial (left) and total (right) knee replacements. Retrieved https://dellavalleortho.com/education/partial-knee-replacement/

At an Individual level, unnecessary imaging can cause avoidable delays in diagnosis and referral, extending the painful time between symptom onset, diagnosis, and proper treatment. Redundant imaging can also be an inhibitory factor for patients who do not have the means to attend these appointments due lack of transportation options or employment flexibility (Lin, et.al., 2020). At an Organizational level, needless imaging exacerbates patient wait times as more people are added to the imaging referral list, delaying access to reasonable imaging (Lin, et.al., 2020). Most significantly, the presence of a standard policy that is not effectively implemented leads to perceived and actual healthcare disparities. This can significantly impact a patient's ability to manage osteoarthritis symptoms and access timely, accurate surgical consultations without unnecessary imaging, expenses, or resource strain, both on an individual and organizational level.

As a sonographer, I see excessive and unecessary imaging on a regular basis, where patients are being sent for ultrasounds to evaluate their knee pain as a result of known degenerative arthritis. The patients are frustrated because they know that the pending results will be inconclusive and will not add to their health care plan. It is often seen as a waste of time and effort, particularly among elderly patients with transportation challenges, or among those with low medical literacy who do not understand why they are there and what their health care team will gain from the results.

Summary

An individual’s Socioeconomic influences and SDoH affect their ability to partake in out-patient symptom mitigation programs (DeCamp et al., 2020). Lack of resources can result in poorly managed symptoms, increased pain, declining quality of life, and a need for an otherwise avoidable major surgery (Messier et al., 2015). This often results in higher number of knee replacement surgeries among lower SES and can be a preventable burden on the healthcare system (Lin etal., 2020). Understanding the factors that surround an individuals’ ability to make health care decisions, shape lifestyle choices, and impact access to treatment and prevention from a SEM lens are important when coming up with treatment and management plans.

Resources

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