Social determinants of health in patients with arthritis: a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System

Methods

Results

The response rate of the 2017 BRFSS was 45.3 % for landlines and 44.5 % for cell phones. There were 449,732 respondents to the 2017 BRFSS. Of the responses to whether they had arthritis (n=446,951), 147,217 reported affirmatively—of which 135,407 were over the age of 45. Of these individuals (having arthritis and 45+ years of age), approximately 25,682, representing a population estimate of 10,765,385 US residents, also responded to the SDOH module, with response rates varying slightly among the SDOH questions. The average age of participants was 65.15 (SD=10.06), with 51.6 % of individuals being over the age of 65, 30.5 % between 54 and 65, and 17.8 % being between 45 and 54 (Table 1). A majority of the sample reported as being White (80.6 %), 10.2 % were Black, and 6.5 % were Hispanic, with those reporting as Native American/Alaskan Native or Asian comprising less than 1 % of the sample each (Table 1). Approximately 74.2 % of the sample had a BMI over 25.00 (Table 1).

SDOH and work/life limitations

We observed statistically noteworthy associations between individuals’ work and life limitations with evaluated domains of SDOH. Patients with issues paying bills showed to have more arthritis-related functional limitations compared to those without payment problems (75.7 vs. 48.9 %; χ²=149.66, p<0.001; Table 2). Similar results were noted in patients reporting work limitations (65.5 vs. 30.2 %; χ²=301.15, p<0.001; Table 2). Individuals who moved more than once in the past 12 months did not result in an increase in arthritis-related functional limitations compared to those who did not move more than once in the past 12 months (51.5 vs. 63.5 %; χ², p=0.006; Table 2), which were also found regarding work limitations (33.4 vs. 55.0 %; χ², p<0.001; Table 2). Findings followed the same pattern for food insecurity, the ability to afford balanced meals, having enough money at the end of the month, and being stressed most or all days. Respondents who reported living in a neighborhood they felt was unsafe or extremely unsafe had more arthritis-related functional limitations (χ²=29.13, p<0.001; Table 2) and work limitations (χ²=37.45, p<0.001; Table 2) compared to those who felt that their neighborhood was safe or extremely safe.

SDOH and pain score

We found remarkable differences in pain scores between variations in SDOH. Persons who reported issues with bill payments had a higher reported arthritis-related pain score compared to those without bill payment issues (6.67 vs. 4.57; Coefficient: 1.61, 95 % CI 1.38–1.84; Table 3). Patients reporting issues of running out of food reported higher arthritis-related pain scores compared to those who did not run out of food (6.66 vs. 4.42; Coefficient: 1.73, 95 % CI 1.54–1.92; Table 3). Individuals who reported an inability to afford balanced meals had a higher reported arthritis-related pain score compared to those able to afford balanced meals (6.57 vs. 4.39; Coefficient: 1.71, 95 % CI 1.53–1.88; Table 3). This trend of higher pain scores among those experiencing negative SDOH circumstances continued through each domain—with each negatively impacted group reporting nearly 2 points higher on the pain scale, except for having frequently moved residences (which was still higher among those moving often; Coefficient: 0.70; 95 %CI: 0.2–1.2, t=2.77, p<0.006; Table 3). Full results are provided in Table 3.

Discussion

Our findings suggest that individuals reporting arthritis as a functional limitation or as a barrier to work were more likely to report experiencing poor SDOH conditions. For example, participants with arthritis were less likely to report being able to pay their bills at the end of the month and were much more likely to have difficulty working or performing daily activities. The association of reporting arthritis and poor SDOH conditions was true for each SDOH domain except for housing permanence. Importantly, we found that increasing pain scores were associated with worse SDOH conditions. In the adjusted model, which controls for age, race, and ethnicity, it was found that higher pain scores were associated with difficulty paying bills, running out of food and money, an inability to afford a healthy diet, low neighborhood safety, and increased stress levels. Higher pain scores were not observed to be meaningfully associated with housing permanence.

The data collected from this study reflect trends found in previous research, which observed higher rates of chronic disease including arthritis in populations with less financial resources or otherwise at a social disadvantage. A recent secondary data analysis of men and women between ages 45 and 79 by Vennu et al. [20] found that those who did not complete their high school education were twice as likely to develop arthritis and chronic obstructive pulmonary disease (COPD) compared to those who finished high school. Multiple studies found a correlation between lower financial income and increased rates of arthritis and obesity [21, 22]. A secondary analysis utilizing individuals with knee arthritis found notable correlations between ethnicity, education, gender, and neighborhood poverty to chronic disease rates [21]. Much like these other studies and chronic illnesses, SDOH are highly correlated with functional status in patients with arthritis, creating a greater need to address these determinants as possible avenues for improved health.

Although SDOH may not be the primary cause of poor health, as Marmot [23] states, they are the cause of causes; thus, addressing them may prove beneficial when forming treatment plans for those with chronic diseases—particularly arthritis. Due to the pathogenesis of arthritis, stressors stemming from negative SDOH and barriers to medication adherence due to financial insecurity can exacerbate individuals’ symptoms and disease progression [17]. An inability to afford or attend necessary treatments such as physical therapy, joint injections, or surgery can hinder the fulfillment of their management plan. For arthritis and rheumatic arthritis in particular, poor SDOH can increase stress, which in turn can alter immune function [24] and lead to higher levels of inflammatory markers [25], thus worsening disease progression [26, 27]. Our own results show that individuals who felt stress most or all days reported more functional and work limitations along with higher pain scores. This implicates an association between SDOH and RA, along with other rheumatic diseases. A study looking at patients with RA found that remission rates at 6 and 12 months were better in individuals without adverse SDOH compared to those with poor SDOH [28]. Another study utilizing data from the American College of Rheumatology’s Rheumatology Informatics System for Effectiveness (RISE) found that functionality was significantly worse in individuals of lower socioeconomic status [29].

The small available research mentioned above strengthens our hypothesis that SDOH have a profound impact on arthritis. With so many determinants influencing health, one solution would not be sufficient to address the underlying needs of patient populations. Some hospitals and organizations have begun work in this area. For example, in 2021, Johns Hopkins Healthcare updated its coding system to provide its patients with more specific care [30]. This classification system, referred to as the ICD-10 code, now includes prompts Z55-Z65, which explicitly address social determinants such as employment status, education, literacy levels, housing and economic circumstances, social support, and much more. With this information, physicians can provide better options to their patients to accommodate their financial or other social needs. Given the universal nature of ICD-10 codes, implementation of these and the development of local and community resources may be coupled to provide an invaluable tool across many more healthcare systems.

In addition to utilizing these resources, physicians should make it a priority to discuss a patient’s social and financial circumstances. Our study and numerous others have proven that SDOH have a profound impact on chronic diseases. Therefore, having a holistic understanding of an individual’s social situation will allow a provider to partner with the patient to create a more personalized healthcare plan that supports adherence and improved health outcomes. We recommend that hospitals and practices provide a list of referrals of resources available for patients who need care, whether it be financial or social.

Future studies should examine whether alterations in patients’ SDOH will change their pain scores. Efforts should also be placed into studies that include individuals younger than 45. Finally, we know that SDOH and arthritis are interrelated, which warrants further investigation into this relationship.

The limitations to this study included data being subjective based on self-reported responses on SDOH and arthritis conducted by the BRFSS survey administration. Additionally, BRFSS did not delineate between other forms of arthritis and osteoarthritis, which limits our ability to explore what forms of arthritis are the most impacted by SDOH. Our study focused on those above the age of 45, leaving out individuals diagnosed with any arthritis from our sample. Further research needs to be done to establish trends of SDOH and arthritis in populations younger than 45 years old. Another limitation of BRFSS is that it alienates individuals without phones, which could limit the results/responses of individuals with serious housing insecurities. Future studies looking into SDOH and arthritis should look at the impact of other demographic variables for which we did not control. Also, our study is cross-sectional in nature and in no way can establish causality. The strengths of this study include a large sample that is more generalizable to the US population than previous SDOH and arthritis studies. This study also focused on more SDOH compared to the research that is available.

Conclusions

Patients with arthritis and poor SDOH, including food and financial insecurity, were more likely to have arthritis with higher pain and work-limiting symptoms than those with positive social determinants, thus confirming our claim that SDOH can have a profound impact on an individual’s severity and the progression of their arthritis. These results further the breadth of literature supporting efforts to address SDOH and reduce morbidity and mortality among many chronic diseases. This study highlights the importance of personalized medicine when caring for patients with arthritis that addresses multiple aspects of health, including food security, safety, and economic health.