Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans

BACKGROUND

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients.

METHODS

Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery.

RESULTS

On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty.

CONCLUSION

Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.

The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population

BACKGROUND

Prior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population.

METHODS

A US integrated health system's total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders.

RESULTS

Of 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78).

CONCLUSION

We observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities.

LEVEL OF EVIDENCE

Level III.

Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 to 2015

BACKGROUND

Trends in racial disparities in total joint arthroplasty (TJA) care have been documented from 1991 to 2008. However, it remains unknown whether numerous national and orthopaedic-specific efforts to reduce these disparities have been successful. The purpose of this study was to investigate trends in racial disparities in TJA utilization and perioperative metrics between black and white patients in the U.S. from 2006 to 2015.

METHODS

The National Inpatient Sample (NIS) was queried to identify black and white patients who underwent primary total knee arthroplasty (TKA) or primary total hip arthroplasty (THA) between 2006 to 2015. Utilization rates, length of stay in the hospital (LOS), discharge disposition, and inpatient complications and mortality were trended over time. Linear and logistic regression analyses were performed to assess changes in disparities over time.

RESULTS

From 2006 to 2015, there were persistent white-black disparities in standardized utilization rates and LOS for both TKA and THA (p < 0.001 for all; ptrend > 0.05 for all). Moreover, there were worsening disparities in the rates of discharge to a facility (rather than home) after both TKA (white compared with black: 40.3% compared with 47.2% in 2006 and 25.7% compared with 34.2% in 2015, ptrend < 0.001) and THA (white compared with black: 42.6% compared with 41.7% in 2006 and 23.4% compared with 29.2% in 2015, ptrend < 0.001) and worsening disparities in complication rates after TKA (white compared with black: 5.1% compared 6.1% in 2006 and 3.9% compared with 6.0% in 2015, ptrend < 0.001).

CONCLUSIONS

There were persistent, and in many cases worsening, racial disparities in TJA utilization and perioperative care between black and white patients from 2006 to 2015 in the U.S. These results were despite national efforts to reduce racial disparities and highlight the need for continued focus on this issue. Although recent work has shown that elimination of racial disparities in TJA care is possible, the present study demonstrates that renewed efforts are still needed on a national level.

The association between race/ethnicity and outcomes following primary shoulder arthroplasty

BACKGROUND

Although prior studies have reported health disparities in total knee and hip arthroplasty, few have evaluated the effect of race/ethnicity on total shoulder arthroplasty, particularly in a setting in which patients have uniform access to care. Because the procedural volume of shoulder arthroplasty has increased dramatically over the past decade, evaluating the association between race/ethnicity and postoperative outcomes is warranted. We sought to evaluate racial/ethnic disparities in adverse postoperative events within a universally insured shoulder arthroplasty cohort in an integrated health care system.

METHODS

An integrated health care system's registry was used to identify patients who underwent elective primary (total or reverse) shoulder arthroplasty from 2005 to 2016. Four mutually exclusive race/ethnicity groups were investigated: white, Asian, black, and Hispanic. Racial differences were evaluated using Cox proportional hazards regression for all-cause revision and conditional logistic regression for 90-day unplanned readmissions and 90-day emergency department (ED) visits while adjusting for confounders.

RESULTS

Of the 8360 shoulder procedures, 2% were performed in Asian patients; 5%, black patients; 9%, Hispanic patients; and 84%, white patients. Compared with white patients, Hispanic patients had a 44% lower revision risk (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97). Black patients had a 45% higher likelihood of a 90-day ED visit (odds ratio, 1.45; 95% confidence interval, 1.12-1.89).

CONCLUSION

We found minority groups to have revision and unplanned readmission risks that were similar to or lower than those of white patients. However, black patients had a higher likelihood of ED visits. Further investigation is needed to determine the reasons for this disparity and identify interventions to mitigate unnecessary ED visits.