JOA - 2026-08-24 - Journal Article
Z-Codes as a Social Determinants of Health Screening Tool for Perioperative Risk Stratification in Total Hip Arthroplasty.
Thota PK, Pondugula P, Pandya S, Sheth NP
Topics
Key Takeaway
THA patients with documented SDOH-related Z-codes had 75% higher 2-year PJI rates (4.55% vs. 2.60%, RR 1.75) and 67% higher revision rates (3.66% vs. 2.20%, RR 1.67) compared to matched controls.
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Summary
This study examined whether ICD-10-CM Z-code documentation of SDOH factors predicts postoperative complications after primary THA using a national database with propensity-matched 1:1 cohorts. SDOH-coded patients showed no difference in primary surgical outcomes at 90 days but had significantly higher ED visits (RR 1.95), readmissions (RR 1.70), and AKI (RR 1.63) in the early period. By 2 years, PJI (RR 1.75), revision THA (RR 1.67), and periprosthetic fractures (RR 1.88) were all significantly elevated in the SDOH cohort.
Key Limitation
Z-code documentation rates vary widely by institution and provider, making the SDOH-negative cohort a heterogeneous group that almost certainly includes patients with unaddressed social risk factors, which confounds the true effect size.
Original Abstract
INTRODUCTION
Social determinants of health (SDOH) substantially influence surgical risk. However, International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z-code documentation as a perioperative screening tool for patients undergoing total hip arthroplasty (THA) has not been examined using electronic health record (EHR)-integrated data. This study aimed to analyze the association between documented SDOH-related Z-codes and postoperative complications following primary THA.
METHODS
Using a national database, patients who underwent primary THA with minimum two-year follow-up were stratified by the presence or absence of SDOH-related Z-codes documented prior to the index procedure. Patients were propensity matched 1:1 to controls, adjusting for demographics and comorbidities. In total, 2,460 propensity-matched patients (1,230 per cohort) were analyzed. The primary outcomes were periprosthetic joint infection (PJI) and revision THA. Surgical outcomes were assessed at 90 days, one year, and two years. Risk ratios (RR) with 95% confidence intervals (CI) were calculated with P-values < 0.05 considered statistically significant.
RESULTS
At 90 days, primary surgical outcomes did not differ significantly between cohorts. Patients who had SDOH demonstrated significantly higher rates of emergency department (ED) visits (RR 1.95, P < 0.001), readmission (RR 1.70, P < 0.001), and acute kidney injury (RR 1.63, P = 0.011). At one year, PJI rates were significantly higher in the SDOH cohort (3.90 versus 2.44%; RR 1.60, P = 0.038). At two years, PJI (4.55 versus 2.60%; RR 1.75, P = 0.009), revision THA (3.66 versus 2.20%; RR 1.67, P = 0.031), and periprosthetic fractures (2.60 versus 1.38%; RR 1.88, P = 0.030) were significantly elevated in the SDOH cohort.
CONCLUSION
This study supports Z-code documentation as a clinically actionable perioperative screening tool for primary THA patients. The progressive emergence of surgical complications in patients who have SDOH Z-codes highlights the importance of sustained postoperative surveillance and dedicated perioperative interventions for this vulnerable population.