Racial disparity in knee arthroplasty utilization in the veterans health administration

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis

BACKGROUND

Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable.

CONCLUSION

Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care.

LEVEL OF EVIDENCE

IV.

Does Value-Based Care Threaten Joint Arthroplasty Access for Vulnerable Patient Populations?: AOA Critical Issues

Health-care expenses have been projected to increase from 17.7% of the U.S. gross domestic product (GDP) in 2014 to 19.6% in 2024. The unsustainable increase in health-care costs has contributed toward support for value-based health care (VBHC) reform. Contemporary VBHC reform programs relevant to orthopaedic surgery include the voluntary Bundled Payments for Care Improvement initiatives (BPCI and BPCI-Advanced) and the Comprehensive Care for Joint Replacement (CJR) program, a mandatory bundled payment program.The purported benefits of transitioning from volume-based reimbursement to value-based reimbursement include moving from a fragmented provider-centered care model to a patient-centered model, with greater care coordination and alignment among providers focused on improving value. VBHC models allow innovative strategies to proactively invest resources to promote value (e.g., the use of nurse navigators) while eliminating unnecessary resources that do not promote value. However, major concerns regarding VBHC include the absence of medical and socioeconomic risk stratification as well as decreased access for higher-risk patients.This article identifies the benefits and potential unintended consequences of VBHC reform, with a focus on joint arthroplasty. We also discuss some potential strategies to promote innovation and improve value without compromising access for vulnerable patients.

Association Between Race/Ethnicity and Total Joint Arthroplasty Utilization in a Universally Insured Population

INTRODUCTION

Previous studies have documented racial and ethnic disparities in total joint arthroplasty (TJA) utilization in the United States. A potential mediator of healthcare disparities is unequal access to care, and studies have suggested that disparities may be ameliorated in systems of universal access. The purpose of this study was to assess whether racial/ethnic disparities in TJA utilization persist in a universally insured population of patients enrolled in a managed healthcare system.

METHODS

This retrospective cohort study used data from a US integrated healthcare system (2015 to 2019). Patients aged 50 years and older with a diagnosis of hip or knee osteoarthritis were included. The outcome of interest was utilization of primary total hip arthroplasty and/or total knee arthroplasty, and the exposure of interest was race/ethnicity. Incidence rate ratios (IRRs) were modeled using multivariable Poisson regression controlling for confounders.

RESULTS

There were 99,548 patients in the hip analysis and 290,324 in the knee analysis. Overall, 10.2% of the patients were Black, 20.5% were Hispanic, 9.6% were Asian, and 59.7% were White. In the multivariable analysis, utilization of primary total hip arthroplasty was significantly lower for all minority groups including Black (IRR, 0.55, 95% confidence interval [CI], 0.52-0.57, P < 0.0001), Hispanic (IRR, 0.63, 95% CI, 0.60-0.66, P < 0.0001), and Asian (IRR, 0.64, 95% CI, 0.61-0.68, P < 0.0001). Similarly, utilization of primary total knee arthroplasty was significantly lower for all minority groups including Black (IRR, 0.52, 95% CI, 0.49-0.54, P < 0.0001), Hispanic (IRR, 0.72, 95% CI, 0.70-0.75, P < 0.0001), and Asian (IRR, 0.60, 95% CI, 0.57-0.63, P < 0.0001) (all in comparison with White as reference).

CONCLUSIONS

In this study of TJA utilization in a universally insured population of patients enrolled in a managed healthcare system, disparities on the basis of race and ethnicity persisted. Additional research is required to determine the reasons for this finding and to identify interventions which could ameliorate these disparities.

Are Body Mass Index Cutoffs Creating Racial, Ethnic, and Gender Disparities in Eligibility for Primary Total Hip and Knee Arthroplasty?

BACKGROUND

Unabated increases in the prevalence of obesity among American adults have disproportionately affected women, Black persons, and Hispanic persons. The purpose of this study was to evaluate for disparity in rates of patient eligibility for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on race and ethnicity and gender by applying commonly used body mass index (BMI) eligibility criteria to two large national databases.

METHODS

We retrospectively reviewed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2015-2019 for primary THA and TKA and the National Health and Nutrition Examination Survey (NHANES) from 2011-2018. Designations of race and ethnicity were standardized between cohorts. BMI cutoffs of <50 kg/m², <45 kg/m², <40 kg/m², and <35 kg/m² were then applied. Rates of eligibility for surgery were examined for each respective BMI cutoff and stratified by age, race and ethnicity, and gender.

RESULTS

143,973 NSQIP THA patients, 242,518 NSQIP TKA patients, and 13,255 NHANES participants were analyzed. Female patients were more likely to be ineligible for surgery across all cohorts for all modeled BMI cutoffs (P < .001 for all). Black patients had relatively lower rates of eligibility across all cohorts for all modeled BMI cutoffs (P < .0001 for all). Hispanic patients had disproportionately lower rates of eligibility only at a BMI cutoff of <35 kg/m².

CONCLUSION

Using BMI cutoffs alone to determine the eligibility for primary THA and TKA may disproportionally exclude women, Black persons, and Hispanic persons. These data raise concerns regarding further disparity and restriction of arthroplasty care to vulnerable populations that are already marginalized.

LEVEL OF EVIDENCE

Retrospective Cohort Study, Level III.

Medicare/Medicaid Insurance Status Is Associated With Reduced Lower Bilateral Knee Arthroplasty Utilization and Higher Complication Rates

Whether to undergo bilateral total knee arthroplasty (BTKA) depends on patient and surgeon preferences. We used the National Inpatient Sample to compare temporal trends in BTKA utilization and in-hospital complication rates among TKA patients ≥50 with Medicare/Medicaid versus private insurance from 2007 to 2016. We used multivariable logistic regression to assess the association between insurance type and trends in utilization and complication rates adjusting for individual-, hospital-, and community-level covariates, using unilateral TKA (UTKA) for reference. Discharge weights were used for nationwide estimates. About 132,400 (49.5%) Medicare/Medicaid patients and 135,046 (50.5%) privately insured patients underwent BTKA. Among UTKA patients, 62.7% had Medicare/Medicaid, and 37.3% had private insurance. Over the study period, BTKA utilization rate decreased from 7.18% to 5.63% among privately insured patients and from 4.59% to 3.13% among Medicaid/Medicare patients (P trend difference <0.0001). In multivariable analysis, Medicare/Medicaid patients were less likely to receive BTKA than privately insured patients. Although Medicare/Medicaid patients were more likely to develop in-hospital complications after UTKA (adjusted odds ratio, 1.06; 95% confidence interval, 1.002 to 1.12; P = 0.04), this relationship was not statistically significant for BTKAs. In this nationwide sample of TKA patients, BTKA utilization rate was higher in privately insured patients compared with Medicare/Medicaid patients. Furthermore, privately insured patients had lower in-hospital complication rates than Medicare/Medicaid patients.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities

BACKGROUND

Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States.

METHODS

A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data.

RESULTS

A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05).

CONCLUSIONS

This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Time to Reflect and Take Action on Health Disparities and Health Inequities

The United States healthcare system underperforms in healthcare access, quality, and cost resulting in some of the poorest health outcomes among comparable countries, despite spending more of its gross national product on healthcare than any other country in the world. Within the United States, there are significant healthcare disparities based on race, ethnicity, socioeconomic status, education level, sexual orientation, gender identity, and geographic location. COVID-19 has illuminated the racial disparities in health outcomes. This article provides an overview of some of the main concepts related to health disparities generally, and in orthopaedics specifically. It provides an introduction to health equity terminology, issues of bias and equity, and potential interventions to achieve equity and social justice by addressing commonly asked questions and then introduces the reader to persistent orthopaedic health disparities specific to total hip and total knee arthroplasty.

Race Differences in Post-Acute Physical Therapy Utilization and Patient-Reported Function after Total Knee Arthroplasty

OBJECTIVE

This observational cohort study included patients of Black and White race and non-Hispanic ethnicity with end-stage knee osteoarthritis who were scheduled to receive total knee arthroplasty (TKA) surgery. We examined whether there are race differences in (1) use of physical therapy (PT) across all post-acute settings and (2) patient-reported physical function following TKA.

METHODS

We collected pre- and post-operative physical function data and post-operative rehabilitation data on 104 Black and White individuals undergoing TKA. Regression analyses and independent samples t-tests were used to explore the predictive value of race on post-operative functional outcome and compare PT utilization within each post-acute setting and across all post-acute rehabilitation settings.

RESULTS

Total PT received was similar between White and Black participants, but there were significant race differences in PT utilization within specific settings. Race did not significantly predict function after TKA, but Black participants had slightly lower self-reported function both before and after surgery than White participants.

CONCLUSION

This is the first study to examine both PT utilization and functional outcomes in a sample of individuals undergoing TKA, and results indicate differences in where post-operative PT is received between Black and White patients.

Exploring Race Differences in Satisfaction with Rehabilitation Following Total Knee Arthroplasty: a Qualitative Study

BACKGROUND

The purpose of this qualitative focus group study was to explore race differences in the rehabilitation experience and satisfaction with rehabilitation following total knee arthroplasty (TKA).

METHODS

We conducted a series of qualitative focus group discussions with groups of Non-Hispanic White and Non-Hispanic Black older adults who recently underwent TKA. We used grounded theory approach, which asks the researcher to develop theory from the data that are collected. Participants discussed barriers and facilitators to accessing rehabilitation after surgery, opinions regarding their physical therapists, the amount of post-operative physical therapy received, and overall satisfaction with the post-operative rehabilitation process.

RESULTS

Thirty-six individuals participated in focus groups. Three major themes emerged: (1) Participants reported overall positive views of their post-TKA rehabilitation experience. They particularly enjoyed one-on-one care, the ability to participate in "prehabilitation", and often mentioned specific interventions they felt were most helpful in their recovery. (2) Despite this, substantial barriers to accessing physical therapy exist. These include suboptimal pain management, copayments and other out-of-pocket costs, and transportation to visits. (3) There were minor differences in the rehabilitation experiences between Black and White participants. Black participants reported longer paths toward surgery and occasional difficulty interacting with rehabilitation providers.

CONCLUSIONS

Individuals undergoing TKA can largely expect positive rehabilitation experiences post-operatively. However, some barriers to post-operative physical therapy exist and may differ between Black and White patients. Physical therapists should increase their awareness of these barriers and work to minimize them whenever possible.

Bilateral vs Unilateral Total Knee Arthroplasty: Racial Variation in Utilization and In-Hospital Major Complication Rates

BACKGROUND

We sought to examine bilateral total knee arthroplasty (BTKA) vs unilateral TKA (UTKA) utilization and in-hospital complications comparing African Americans (AAs) and Whites.

METHODS

In this retrospective analysis of patients ≥50 years who underwent elective primary TKA, the (2007-2016) database of the Healthcare Cost and Utilization Project (National Inpatient Sample) was used. We computed differences in temporal trends in utilization and major in-hospital complication rates of BTKA vs UTKA comparing AAs and Whites. We performed multivariable logistic regression models to assess racial differences in trends adjusting for individual-, hospital- and community-level variables. Discharge weights were used to enable nationwide estimates. We used multiple imputation procedures to impute values for 12% missing race information.

RESULTS

An estimated 276,194 BTKA and 5,528,429 UTKA were performed in the US. The proportion of BTKA among all TKAs declined, and AAs were significantly less likely to undergo BTKA compared to Whites throughout the study period (trend P = .01). In-hospital complication rates for UTKA were higher in AAs compared to Whites throughout the study period (trend P < .0001). However, for BTKA, the in-hospital complication rates varied between Whites and AAs throughout the study period (trend P = .09).

CONCLUSION

In this nationwide sample of patients who underwent total knee arthroplasty from 2007 to 2016, the utilization of BTKA was higher in Whites compared to AAs. On the other hand, while AAs have consistently higher in-hospital complication rates in UTKA over the time period, this pattern was not consistent for BTKA.

Primary Total Hip Arthroplasty in Hispanic/Latino Patients: An Updated Nationwide Analysis of Length of Stay, 30-Day Outcomes, and Risk Factors

Background

This study explored recent time trends in length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) pertaining to total hip arthroplasty in the Hispanic and Latino population.

Methods

A total of 4107 Hispanic and Latino patients who underwent primary total hip arthroplasty between 2011 and 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Annual trends in LOS and 30-day outcomes (readmission, reoperation, complications, and mortality) were calculated using univariate mixed-effect regression analyses. Risk factors for AEs were determined using multivariate analyses.

Results

Between 2011 and 2017, there was a significant reduction in LOS >2 midnights (67.6% to 29.5%, P < .001) among Hispanic patients, which was similar to that among non-Hispanic white patients and was also accompanied with improvements in comorbidity profiles and shorter operative times. Postoperatively, the annual rates of 30-day outcomes were comparable with those of white patients (P > .05). Chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use were the strongest independent predictors for AEs.

Conclusions

In the context of historically lower arthroplasty outcomes among the Hispanic and Latino population, current evidence suggests a receding tide, with annual trends showing significantly shorter LOS and comparable overall 30-day outcomes with whites. Patients with chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use are at the highest risk for developing 30-day AEs.

Socioeconomic disparities in the utilization of spine augmentation for patients with osteoporotic fractures: an analysis of National Inpatient Sample from 2011 to 2015

BACKGROUND CONTENT

Vertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty.

PURPOSE

The purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures.

METHODS

With the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value <.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage.

RESULTS

We identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58-0.70, p<.001), Hispanic patients (OR=0.79, 95% CI: 0.73-0.86, p<.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70-0.89, p<.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53-0.66, p<.001), private insurance (OR=0.90, 95% CI: 0.85-0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47-0.69, p<.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70-1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71-0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58-0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare.

CONCLUSIONS

Our study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.

Disparities in Access to Musculoskeletal Care: Narrowing the Gap: AOA Critical Issues Symposium

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

Predictors of Future Contralateral Carpal Tunnel Release at the Time of Unilateral Surgery

PURPOSE

We assessed factors at the time of unilateral carpal tunnel release (CTR) for carpal tunnel syndrome to create a prediction formula for future CTR.

METHODS

We retrospectively identified 1,013 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. A multivariable logistic regression model was used to identify independent factors associated with future contralateral CTR. A prediction formula was created and its validity was assessed by calculating the C-statistic for model discrimination and the Hosmer-Lemeshow goodness-of-fit test and calibration slope for model calibration. We tested the external validity of our formula using a sample of 100 random patients who underwent CTR at a second tertiary care referral center from October 2004 to August 2016.

RESULTS

Contralateral carpal tunnel symptoms and preoperative contralateral electrodiagnostic study severity were associated with increased likelihood of contralateral CTR, whereas black race and chronic kidney disease were associated with decreased likelihood of contralateral CTR. We constructed a prediction formula for the probability of undergoing contralateral CTR at 5.5 years' follow-up.

CONCLUSIONS

The probability of future contralateral CTR may be useful in preoperative counseling for select patients who are reasonable candidates for unilateral, staged bilateral, or simultaneous bilateral CTR. Our prediction formula can be an adjunct tool for shared decision making but it does not replace the experienced clinician's judgment based on the patient's history, physical examination, and confirmatory testing.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Insurance Status Affects In-Hospital Complication Rates After Total Knee Arthroplasty

Insurance status has been shown to be a predictor of patient morbidity and mortality. The purpose of this study was to evaluate the effect of patient insurance status on the in-hospital complication rates following total knee arthroplasty. Data were obtained from the Nationwide Inpatient Sample (2004 through 2011). Patient demographics and comorbidities were analyzed and stratified by insurance type. Analysis was performed with a matched cohort comparing complication rates between patients with Medicare vs private insurance using the coarsened exact matching algorithm and multivariable logistic regression. A total of 1,352,505 patients (Medicare, 57.8%; private insurance, 35.6%; Medicaid/uninsured, 3.1%; other, 3.3%; unknown, 0.2%) fulfilled the inclusion criteria. The matched cohort analysis comparing Medicare with privately insured patients showed significantly higher risk of mortality (relative risk [RR], 1.34; P<.001), wound dehiscence (RR, 1.32; P<.001), central nervous system complications (RR, 1.16; P=.030), and gastrointestinal complications (RR, 1.13; P<.001) in Medicare patients, whereas privately insured patients had a higher risk of cardiac complications (RR, 0.93; P=.003). Independent of insurance status, older patients and patients with an increased comorbidity index were also associated with a higher complication rate and mortality following total knee arthroplasty. These data suggest that insurance status may be considered as an independent risk factor for increased complications when stratifying patients preoperatively for total knee replacement. Further research is needed to investigate the disparities in these findings to optimize patient outcomes following total knee arthroplasty. [Orthopedics. 2018; 41(3):e340-e347.].

Racial Variation in Total Knee Replacement in a Diverse Nationwide Clinical Trial

OBJECTIVE

Racial variation in total knee replacement (TKR) utilization in the United States has been reported in administrative database studies. We investigated racial variation in TKR procedures in a diverse cohort with severe knee pain followed in an ongoing clinical trial.

METHODS

VITAL (VITamin D and OmegA-3 TriaL) is a nationwide, randomized controlled trial of 25,874 adults, 20% of whom are black. We identified a subgroup highly likely to have knee osteoarthritis based on severity of knee pain, physician-diagnosed knee osteoarthritis, and inability to walk 2 to 3 blocks without pain. Participants completed a modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and self-reported incident TKR annually in follow-up. Using Cox regression, we analyzed the association of black versus white race with TKR, adjusting for demographic and socioeconomic characteristics, comorbidities, and WOMAC pain and function.

RESULTS

Among 1070 participants who met the inclusion criteria, black participants reported worse baseline WOMAC pain (45 vs. 32, P < 0.001) and worse function (45 vs. 32, P < 0.001). During a median of 3.6 years (interquartile range, 3.2, 3.8 years) of follow-up, TKRs were reported by 180 participants. Black participants were less likely to undergo TKR (11% vs. 19%). After adjustment, the hazard ratio for TKR for black versus white participants was 0.51 (95% confidence interval, 0.32-0.81). Lower use of TKR among black participants was observed across all levels of income and education.

CONCLUSIONS

Despite worse baseline knee pain and function, black participants had much lower adjusted risk of having TKR than white participants, demonstrating persistent racial disparity in TKR utilization.

Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Health Care System, 2001-2013

OBJECTIVE

To examine black-white and Hispanic-white differences in total knee arthroplasty from 2001 to 2013 in a large cohort of patients diagnosed with osteoarthritis (OA) in the Veterans Affairs (VA) health care system.

METHODS

Data were from the VA Musculoskeletal Disorders cohort, which includes data from electronic health records of more than 5.4 million veterans with musculoskeletal disorders diagnoses. We included white (non-Hispanic), black (non-Hispanic), and Hispanic (any race) veterans, age ≥50 years, with an OA diagnosis from 2001-2011 (n = 539,841). Veterans were followed from their first OA diagnosis until September 30, 2013. As a proxy for increased clinical severity, analyses were also conducted for a subsample restricted to those who saw an orthopedic or rheumatology specialist (n = 148,844). We used Cox proportional hazards regression to examine racial and ethnic differences in total knee arthroplasty by year of OA diagnosis, adjusting for age, sex, body mass index, physical and mental diagnoses, and pain intensity scores.

RESULTS

We identified 12,087 total knee arthroplasty procedures in a sample of 473,170 white, 50,172 black, and 16,499 Hispanic veterans. In adjusted models examining black-white and Hispanic-white differences by year of OA diagnosis, total knee arthroplasty rates were lower for black than for white veterans diagnosed in all but 2 years. There were no Hispanic-white differences regardless of when diagnosis occurred. These patterns held in the specialty clinic subsample.

CONCLUSION

Black-white differences in total knee arthroplasty appear to be persistent in the VA, even after controlling for potential clinical confounders.

Social Context and Value-Based Care: A Capabilities Approach for Addressing Health Disparities

Racial disparities in health are persistent and pervasive in the United States. Researchers and policymakers have known for decades that access to health care is not sufficient for addressing health disparities because of the socially situated roots of the disparities. We argue that the lack of progress in alleviating health disparities is the result of a lack of overarching framework to guide both policymakers and researchers in their efforts. We propose Amartya Sen's capabilities approach as a theoretical framework that is expansive enough to address both the social context in which health occurs as well as the quality of health care provided. In this article, we use a subset of veterans receiving care from the Veterans Health Administration to review the theoretical concepts that link social inequalities with health disparities. Next, we provide empirical evidence of disparities in health based on race within the Veterans Health Administration, and we then provide a theoretical explanation for those disparities that exist at a system level. We close with a detailed examination of the applicability of the capabilities approach in addressing health disparities in the United States.

Racial/Ethnic Disparity in Rates and Outcomes of Total Joint Arthroplasty

Racial/ethnic disparity in total joint arthroplasty (TJA) has grown over the last two decades as studies have documented the widening gap between Blacks and Whites in TJA utilization rates despite the known benefits of TJA. Factors contributing to this disparity have been explored and include demographics, socioeconomic status, patient knowledge, patient preference, willingness to undergo TJA, patient expectation of post-arthroplasty outcome, religion/spirituality, and physician-patient interaction. Improvement in patient knowledge by effective physician-patient communication and other methods can possibly influence patient's perception of the procedure. Such interventions can provide patient-relevant data on benefits/risks and dispel myths related to benefits/risks of arthroplasty and possibly reduce this disparity. This review will summarize the literature on racial/ethnic disparity on TJA utilization and outcomes and the factors underlying this disparity.

Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty

BACKGROUND

Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S.

POPULATION

We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases.

METHODS

We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated.

RESULTS

In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites.

CONCLUSIONS

Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial

BACKGROUND

A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA.

QUESTIONS/PURPOSES

We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA?

METHODS

Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report.

RESULTS

The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679).

CONCLUSION

A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Racial Disparities in Lower Extremity Arthroplasty Outcomes and Use

Race-associated disparities often occur in patients who undergo lower extremity total joint arthroplasty (TJA). Although it is imperative to elucidate and describe the disparities in race and ethnicity that may influence patient perception, satisfaction, and surgical outcomes, there is a paucity of reports detailing the nature of potential racial disparities in TJA. Therefore, the purpose of this review was to examine racial and ethnic disparities in the (1) physician-patient relationship; (2) use of TJA; (3) intraoperative and 30-day postoperative complications; and (4) patient-reported outcomes. Although there are limited studies that evaluated this topic, it has been shown that there are race-specific differences in physician-patient relationships. Specifically, African American patients report lower satisfaction rates in communication with their physician than their Caucasian counterparts and physicians were more apt to describe African Americans as less "medically cooperative." The majority of the studies the authors found regarding TJA use indicated that African Americans and Hispanics were less likely to undergo lower extremity TJA than Caucasians. Furthermore, racial minorities may have higher 30-day readmission and intra- and postoperative complication rates compared with Caucasians. Despite these compelling findings, concrete conclusions are difficult to make due to the presence of multiple confounding patient factors, and more studies examining the racial and ethnic disparities in patients with TJA are needed.

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data

OBJECTIVE

To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time.

METHODS

We used data from the US Medicare Program (MedPAR data) for years 1991-2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African-American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African-Americans, and whether disparities decreased over time.

RESULTS

In 1991, the use of primary TKA was 36% lower for African-Americans compared with Caucasians (20.6 per 10,000 for African-Americans; 32.1 per 10,000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African-Americans (41.5 per 10,000 for African-Americans; 68.8 per 10,000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black-White disparities in 30-day hospital readmission increased significantly from 1991-2008 among three patient cohorts. For example in 1991 30-day readmission rates for African-Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African-Americans were 24% higher (p<0.05 for change in disparity). Similarly, black-white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05).

CONCLUSIONS

In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.

Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010

CONTEXT

Total knee arthroplasty (TKA) is one of the most common and costly surgical procedures performed in the United States.

OBJECTIVE

To examine longitudinal trends in volume, utilization, and outcomes for primary and revision TKA between 1991 and 2010 in the US Medicare population.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort of 3,271,851 patients (aged ≥65 years) who underwent primary TKA and 318 563 who underwent revision TKA identified in Medicare Part A data files.

MAIN OUTCOME MEASURES

We examined changes in primary and revision TKA volume, per capita utilization, hospital length of stay (LOS), readmission rates, and adverse outcomes.

RESULTS

Between 1991 and 2010 annual primary TKA volume increased 161.5% from 93,230 to 243,802 while per capita utilization increased 99.2% (from 31.2 procedures per 10,000 Medicare enrollees in 1991 to 62.1 procedures per 10,000 in 2010). Revision TKA volume increased 105.9% from 9650 to 19,871 while per capita utilization increased 59.4% (from 3.2 procedures per 10,000 Medicare enrollees in 1991 to 5.1 procedures per 10,000 in 2010). For primary TKA, LOS decreased from 7.9 days (95% CI, 7.8-7.9) in 1991-1994 to 3.5 days (95% CI, 3.5-3.5) in 2007-2010 (P < .001). For primary TKA, rates of adverse outcomes resulting in readmission remained stable between 1991-2010, but rates of all-cause 30-day readmission increased from 4.2% (95% CI, 4.1%-4.2%) to 5.0% (95% CI, 4.9%-5.0%) (P < .001). For revision TKA, the decrease in hospital LOS was accompanied by an increase in all-cause 30-day readmission from 6.1% (95% CI, 5.9%-6.4%) to 8.9% (95% CI, 8.7%-9.2%) (P < .001) and an increase in readmission for wound infection from 1.4% (95% CI, 1.3%-1.5%) to 3.0% (95% CI, 2.9%-3.1%) (P < .001).

CONCLUSIONS

Increases in TKA volume have been driven by both increases in the number of Medicare enrollees and in per capita utilization. We also observed decreases in hospital LOS that were accompanied by increases in hospital readmission rates.

Orthopedic communication about osteoarthritis treatment: Does patient race matter?

OBJECTIVE

To understand racial disparities in the use of total joint replacement, we examined whether there were racial differences in patient-provider communication about treatment of chronic knee and hip osteoarthritis in a sample of African American and white patients referred to Veterans Affairs orthopedic clinics.

METHODS

Audio recorded visits between patients and orthopedic surgeons were coded using the Roter Interaction Analysis System and the Informed Decision-Making model. Racial differences in communication outcomes were assessed using linear regression models adjusted for study design, patient characteristics, and clustering by provider.

RESULTS

The sample (n = 402) included 296 white and 106 African American patients. Most patients were men (95%) and ages 50-64 years (68%). Almost half (41%) reported an income <$20,000. African American patients were younger and reported lower incomes than white patients. Visits with African American patients contained less discussion of biomedical topics (β = -9.14; 95% confidence interval [95% CI] -16.73, -1.54) and more rapport-building statements (β = 7.84; 95% CI 1.85, 13.82) than visits with white patients. However, no racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, patient activation/engagement statements, physician verbal dominance, display of positive affect by patients or providers, or discussion related to informed decision making.

CONCLUSION

In this sample, communication between orthopedic surgeons and patients regarding the management of chronic knee and hip osteoarthritis did not, for the most part, vary by patient race. These findings diminish the potential role of communication in Veterans Affairs orthopedic settings as an explanation for well-documented racial disparities in the use of total joint replacement.

Defining racial and ethnic disparities in THA and TKA

BACKGROUND

For minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.

QUESTIONS/PURPOSES

We therefore (1) defined utilization disparities for total joint arthroplasty in racial and ethnic minorities, (2) delineated patient and provider factors contributing to the lower total joint arthroplasty utilization, and (3) discussed potential interventions and future research that may increase total joint arthroplasty utilization by racial and ethnic minorities.

METHODS

We searched the MEDLINE database and identified 67 articles, 21 of which we excluded. By searching Google and Google Scholar and reference lists of the included articles, we identified 40 articles for this review. Utilization disparities were defined by documented lower utilization of THA or TKA in specific racial or ethnic groups.

RESULTS

Lower utilization of THA and TKA among some racial and ethnic minority groups (African Americans, Hispanics) is not explained by decreased disease prevalence or disability. At least some utilization disparities are independent of income, geographic location, education, and insurance status. Causal factors related to racial and ethnic disparities may be related in part to patient factors such as health literacy, trust, and preferences. Provider unconscious or conscious biases or beliefs also play a role in at least some healthcare disparities.

CONCLUSIONS

Racial and ethnic THA and TKA utilization disparities exist. These disparities are not explained by lower disease prevalence. The existing data suggest patient education, improved health literacy regarding THA and TKA, and a patient-provider relationship leading to improved trust would be beneficial. Research providing a better understanding of the root causes of these disparities is needed.

A population-based study of trends in the use of total hip and total knee arthroplasty, 1969-2008

OBJECTIVE

To study the rates of use of total hip arthroplasty (THA) and total knee arthroplasty (TKA) during the past 4 decades.

METHODS

The Rochester Epidemiology Project was used to identify all Olmsted County, Minnesota, residents who underwent THA or TKA from January 1, 1969, through December 31, 2008. We used a population-based approach because few data are available on long-term trends in the use of THA and TKA in the United States. Rates of use were determined by age- and sex-specific person-years at risk. Poisson regression was used to assess temporal trends by sex and age group.

RESULTS

The age- and sex-adjusted use of THA increased from 50.2 (95% confidence interval [CI], 40.5-59.8) per 100,000 person-years in 1969-1972 to 145.5 (95% CI, 134.2-156.9) in 2005-2008, whereas TKA increased markedly from 31.2 (95% CI, 25.3-37.1) per 100,000 person-years in 1971-1976 to 220.9 (95% CI, 206.7-235.0) in 2005-2008. For both procedures, use was greater among females, and the rate generally increased with age.

CONCLUSION

In this community, TKA and THA use rates have increased steadily since the introduction of the procedures and continue to increase for all age groups. On the basis of these population-based data, the probable need for TKA and THA exceeds current federal agency projections.

The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting

BACKGROUND

The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored.

OBJECTIVE

To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment.

DESIGN

Prospective, observational study.

PARTICIPANTS

African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics.

MAIN MEASURES

Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons' notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment.

RESULTS

Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26-0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36-1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16-1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21-1.54, P = 0.27).

CONCLUSIONS

In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

The personal interview: assessing the potential for personality similarity to bias the selection of orthopaedic residents

PURPOSE

The selection of medical students for training in orthopaedic surgery consists of an objective screening of cognitive skills to secure interviews for the brightest candidates, followed by subjective measures of candidates to confirm whether applicants are worthy of further consideration. The personal interview and its potential biased impact on the orthopaedic workforce were evaluated.

METHOD

During 2004-2006 at the Penn State College of Medicine, the authors performed a prospective cohort study in which 30 consenting interviewers and 135 interviewees completed the Myers-Briggs Type Indicator before the interviews. Completed surveys were evaluated after submitting the resident selection list to the National Residency Matching Program, and candidate rankings based solely on the personal interview were analyzed.

RESULTS

Clinicians ranked candidates more favorably when they shared certain personality preferences (P = .044) and when they shared the preference groupings of the quadrant extrovert-sensing and either the function pair sensing-thinking (P = .007) or the temperament sensing-judging (P = .003), or the function pair sensing-feeling and the temperament sensing-judging (P = .029). No associations existed between personality preferences and interviewee rankings performed by basic scientists and resident interviewers.

CONCLUSIONS

The results support the hypothesis that, within the department studied, there was a significant association between similarities in personality type and the rankings that individual faculty interviewers assigned to applicants at the completion of each interview session. The authors believe that it is important for the faculty member to recognize that this tendency exists. Finally, promoting diversity within the admission committee may foster a diverse resident body and orthopaedic workforce.

Adverse events after total knee arthroplasty: a national Medicare study

Adverse events from 2033 total knee arthroplasty patients were documented by nonphysician abstractors. The annual rate of adverse events from 2002 to 2004 was 9.2%, 6.4%, and 5.8%, respectively. Congestive heart failure (odds ratio, 2.1; 95% confidence interval, 1.2-3.5; P < .01) and chronic obstructive pulmonary disease (odds ratio, 1.8; 95% confidence interval, 1.2-2.7; P < .01) were associated with a significantly increased risk of experiencing any adverse event during the index hospitalization. The 30-day postprocedure rate of readmission for all causes was 5.5%. Experiencing an adverse event during the index hospitalization increased the length of stay (P < .001). The rate of symptomatic venous thromboembolism 30 days postprocedure was 1.7%. The 30-day postprocedure mortality rate was 0.3%. Experiencing any adverse event was associated with an increased 30-day postprocedure mortality (P < .001). Compared with previous studies of Medicare claims, these data reveal a substantial decrease in the mortality rate, an increased readmission rate, and no substantial change in the rate of venous thromboembolism.

Reduced rates of primary joint replacement for osteoarthritis in Italian and Greek migrants to Australia: the Melbourne Collaborative Cohort Study

Introduction

Racial and ethnic disparities in rates of total joint replacement have been described, but little work has been done in well-established migrant groups. The aim of this study was to compare the rates of primary joint replacement for osteoarthritis for Italian and Greek migrants to Australia and Australian-born individuals.

Methods

Eligible participants (n = 39,023) aged 27 to 75 years, born in Italy, Greece, Australia and the United Kingdom, were recruited for the Melbourne Collaborative Cohort Study between 1990 and 1994. Primary hip and knee replacement for osteoarthritis between 2001 and 2005 was determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry.

Results

Participants born in Italy and Greece had a lower rate of primary joint replacement compared with those born in Australia (hazard ratio [HR] 0.32, 95% confidence interval [CI] 0.26 to 0.39, P < 0.001), independent of age, gender, body mass index, education level, and physical functioning. This lower rate was observed for joint replacements performed in private hospitals (HR 0.17, 95% CI 0.13 to 0.23), but not for joint replacements performed in public hospitals (HR 0.96, 95% CI 0.72 to 1.29).

Conclusions

People born in Italy and Greece had a lower rate of primary joint replacement for osteoarthritis in this cohort study compared with Australian-born people, which could not simply be explained by factors such as education level, physical functioning, and weight. Although differential access to health care found in the population may explain the different rates of joint replacement, it may be that social factors and preferences regarding treatment or different rates of progression to end-stage osteoarthritis in this population are important to ethnic disparity.

Investigating racial differences in coping with chronic osteoarthritis pain

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (beta = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.

The impact of race and ethnicity on receipt of family planning services in the United States

OBJECTIVE

This study sought to examine the independent effect of patient race or ethnicity on the use of family planning services and on the likelihood of receiving counseling for sterilization and other birth control methods.

METHODS

This study used national, cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG). Our analysis included women aged 18-44 years who had heterosexual intercourse within the past 12 months, who were not actively seeking to get pregnant, and who had not undergone surgical sterilization. The primary outcome was receipt of family planning services within the past 12 months. Specific services we examined were (1) provision of or prescription for a method of birth control, (2) checkup related to using birth control, (3) counseling about sterilization, and (4) counseling about birth control.

RESULTS

Although we found no racial/ethnic differences in the overall use of family planning services, there were racial/ethnic differences in the specific type of service received. Hispanic and black women were more likely than white women to receive counseling for birth control (adjusted OR 1.5, 95% confidence interval [CI] 1.2, 1.8, and adjusted OR 1.3, 95% CI 1.1, 1.7, respectively). Hispanic women were more likely than white women to report having been counseled about sterilization (adjusted OR 1.5, 95% CI 1.0, 2.3).

CONCLUSIONS

Minority women were more likely to receive counseling about sterilization and other birth control methods. However, there were no differences in access to family planning services by race or ethnicity. Future studies are needed to examine the quality and content of contraceptive counseling received by minority compared with nonminority women.

Utilization of joint arthroplasty: racial and ethnic disparities in the Veterans Affairs Health Care System

Studies within the Veterans Administration health care system have been very useful in identifying the existence of racial and ethnic disparities with regard to patient utilization of hip and knee joint arthroplasty. Existing studies have focused on three factors: estimates of joint arthroplasty utilization,postoperative outcomes, and patient-related variables (eg, expectations of and familiarity with the procedure, religious beliefs). Although Veterans Administration-based studies have produced helpful data, these data are limited because the populations studied are not representative of the larger US population. Specifically, studies from the Veterans Administration health care system are composed of a predominantly male patient demographic;in addition, patients are more likely to have lower income and education levels than the US population as a whole.

Disparities in orthopaedic surgical intervention

Race- and ethnicity-based health disparities have been identified both in health care generally and in orthopaedics specifically. Despite this body of research, it remains unclear why these disparities exist. Research has been done on disparities in patients with cardiovascular disease and diabetes, as well as in patients who are candidates for hip or knee arthroplasty. With regard to disparities in orthopaedics, differences in the rates of total hip and knee replacement surgery have been studied the most extensively. To better understand health disparities in orthopaedics and in health care as a whole, patient-, provider-, and health care-related factors must be examined more fully.

Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System

Elective total joint arthroplasty is an effective treatment option for end-stage osteoarthritis of the hip and knee. The demand for arthroplasty is anticipated to increase as the proportion of older patients with hip and knee osteoarthritis continues to rise in the United States and worldwide. Studies have documented marked racial and ethnic differences in the utilization rates of hip and knee arthroplasty in the United States. The reasons for these differences are complex and include patient-level factors, such as treatment preference; provider-level factors, such as physician-patient communication style; and system-level factors, such as access to specialist care. Most of the studies on racial and ethnic disparities in joint arthroplasty utilization have been based on data from the Medicare database. However, Veterans Administration-based studies have recently confirmed these findings and have indicated potential patient-level factors, such as patient perception of and familiarity with joint arthroplasty, that may play a role in this disparity.