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Tong Y, Rajahraman V, Gupta R, Schwarzkopf R, Rozell JC. Patient Demographic Factors Impact KOOS JR Response Rates for Total Knee Arthroplasty Patients. J Knee Surg 2024; 37:784-788. [PMID: 38776975 DOI: 10.1055/s-0044-1787055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) is a validated patient-reported measure for assessing pain and function following total knee arthroplasty (TKA). This study investigates how patient demographic factors (i.e., age, sex, and race) correlate with KOOS JR response rates. This was a retrospective cohort study of adult, English-speaking patients who underwent primary TKA between 2017 and 2023 at an academic institution. KOOS JR completion status-complete or incomplete-was recorded within 90 days postoperatively. Standard statistical analyses were performed to assess KOOS JR completion against demographic factors. Among 2,883 total patients, 70.2% had complete and 29.8% had incomplete KOOS JR questionnaires. Complete status (all p < 0.01) was associated with patients aged 60 to 79 (71.8%), white race (77.6%), Medicare (81.7%), marriage (76.8%), and the highest income quartile (75.7%). Incomplete status (all p < 0.001) was associated with patients aged 18 to 59 (64.4%), Medicaid (82.4%), and lower income quartiles (41.6% first quartile, 36.8% third quartile). Multiple patient demographic factors may affect KOOS JR completion rates; patients who are older, white, and of higher socioeconomic status are more likely to participate. Addressing underrepresented groups is important to improve the utility and generalizability of the KOOS JR.
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Affiliation(s)
- Yixuan Tong
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Vinaya Rajahraman
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Rajan Gupta
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Adu Y, Hurley J, Ring D. Are There Racial and Ethnic Variations in Patient Attitudes Toward Hip and Knee Arthroplasty for Osteoarthritis? A Systematic Review. Clin Orthop Relat Res 2024; 482:1417-1424. [PMID: 38393955 PMCID: PMC11272247 DOI: 10.1097/corr.0000000000003021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND It is not clear why people who identify as Black or Hispanic are less likely to undergo discretionary musculoskeletal surgery such as arthroplasty for osteoarthritis of the hip or knee. Inequities and mistrust are important factors to consider. The role of socioeconomic factors and variation in values, attitudes, and beliefs regarding discretionary procedures are less well understood. A systematic review of the evidence regarding mindsets toward knee and hip arthroplasty among Black and Hispanic people could inform attempts to limit disparities in care. QUESTIONS/PURPOSES In a systematic review of qualitative and quantitative evidence, we asked: (1) What factors are associated with racial and ethnic variations in attitudes toward discretionary hip and knee arthroplasty for osteoarthritis? (2) Do studies that investigate racial and ethnic variations in mindsets toward discretionary orthopaedic care control for potential confounding by socioeconomic factors? METHODS A systematic search of PubMed, Cochrane, and Embase (last searched August 2023) for studies that addressed racial and ethnic variations in mindsets toward discretionary musculoskeletal care use was conducted. We excluded studies that were not published in English, lacked full-text availability, and those that documented patient approaches without comparing them to the willingness to undergo a discretionary procedure. Twenty-one studies were included-14 quantitative and seven qualitative-including 8472 patients. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. The studies included demonstrated low risk of bias: five quantitative studies lacked detail regarding nonresponse bias and one qualitative study lacked details regarding the racial and ethnic composition of its cohort. To answer our first research question, we categorized themes associated with racial differences in mindsets toward discretionary care and recorded the presence of associations in quantitative studies. To answer our second question, we identified whether quantitative studies address potential confounding with socioeconomic factors. There were no randomized trials, so no meta-analysis was performed. RESULTS In general, self-identified Black and Hispanic patients had a lower preference for hip and knee arthroplasty than self-identified White patients. Black patients were more likely to regard osteoarthritis as a natural and irremediable part of aging and prefer home remedies. Both Black and Hispanic patients valued support from religion and were relatively cost-conscious. Black and Hispanic patients had lower perception of benefit, were less familiar with the procedure, had higher levels of fear regarding surgery and recovery, and had more-limited trust in care. Generally, Black and Hispanic social networks tended to address these concerns, whereas White social networks were more likely to discuss the benefits of surgery. Thirteen of 14 quantitative studies considered and accounted for potential confounding socioeconomic variables in their analyses. CONCLUSION The observation that lower preference for discretionary arthroplasty among Black and Hispanic patients is independent from socioeconomic factors and is related to accommodation of aging, preference for agency (home remedies), greater consideration of costs, recovery concerns, and potential harms directs orthopaedic surgeons to find ways to balance equitable access to specialty care and discretionary surgery while avoiding undermining effective accommodation strategies. It is important not to assume that lower use of discretionary surgery represents poorer care or is a surrogate marker for discrimination. LEVEL OF EVIDENCE Level III, therapeutic study.
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MESH Headings
- Humans
- Arthroplasty, Replacement, Knee/psychology
- Arthroplasty, Replacement, Hip/psychology
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Hip/ethnology
- Osteoarthritis, Hip/psychology
- Osteoarthritis, Knee/surgery
- Osteoarthritis, Knee/ethnology
- Osteoarthritis, Knee/psychology
- Healthcare Disparities/ethnology
- Hispanic or Latino/psychology
- Black or African American/psychology
- Health Knowledge, Attitudes, Practice/ethnology
- Socioeconomic Factors
- Attitude to Health/ethnology
- Ethnicity/psychology
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Affiliation(s)
- Yaw Adu
- School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Jack Hurley
- School of Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - David Ring
- Department of Orthopaedic Surgery, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Tong Y, Rajahraman V, Gupta R, Davidovitch RI, Schwarzkopf R, Rozell JC. Patient Demographic Factors Affect Response Rates to Patient-Reported Outcome Measures for Total Hip Arthroplasty Patients. J Arthroplasty 2024:S0883-5403(24)00633-8. [PMID: 38959987 DOI: 10.1016/j.arth.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The Hip Disability and Osteoarthritis Outcome Score (HOOS JR) is a widely used patient-reported outcome measures questionnaire for total hip arthroplasty (THA). However, not all patients choose to complete HOOS JR, and thus, a subset of the THA population may be underrepresented. This study aims to investigate the association between patient demographic factors and HOOS JR response rates. METHODS This was a retrospective cohort study of adult, English-speaking patients who underwent primary THA by a fellowship-trained arthroplasty surgeon between 2017 and 2023 at a single, high-volume academic institution. The HOOS JR completion status-complete or incomplete-was recorded for each patient within 90 days of surgery. Standard statistical analyses were performed to assess completion against multiple patient demographic factors. RESULTS Of the 2,908 total patients, 2,112 (72.6%) had complete and 796 (27.4%) had incomplete HOOS JR questionnaires. Multivariate analysis yielded statistical significance (P < .05) for the distribution of patient age, race, insurance, marital status, and income quartile with respect to questionnaire completion. Patient sex or religion did not affect response rates. Failure to complete HOOS JR (all P < .001) was associated with patients aged 18 to 39 (59.8%), who identified as Black (36.4%) or "other" race (39.6%), were never married (38%), and were in the lower half income quartiles (43.9%, 35.9%) when compared to the overall incomplete rate. CONCLUSIONS Multiple patient demographic factors may affect the HOOS JR response rate. Overall, our analyses suggest that older patients who identify as White and are of higher socioeconomic status are more likely to participate in the questionnaire. Efforts should focus on capturing patient groups less likely to participate to elucidate more generalizable trends in arthroplasty outcomes.
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Affiliation(s)
- Yixuan Tong
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Vinaya Rajahraman
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Rajan Gupta
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Roy I Davidovitch
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Abella MKIL, Thorne T, Hayashi J, Finlay AK, Frick S, Amanatullah DF. An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes. Orthopedics 2024; 47:e131-e138. [PMID: 38285555 DOI: 10.3928/01477447-20240122-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].
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Myers S, Kenzik K, Allee L, Dechert T, Theodore S, Jaffe A, Sanchez SE. Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital. Surg Infect (Larchmt) 2024; 25:101-108. [PMID: 38301176 DOI: 10.1089/sur.2023.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.
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Affiliation(s)
- Sara Myers
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Lisa Allee
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tracey Dechert
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sheina Theodore
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Abraham Jaffe
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Race. J Arthroplasty 2024:S0883-5403(24)00072-X. [PMID: 38311298 DOI: 10.1016/j.arth.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Dubin JA, Bains SS, Chen Z, Salib CG, Nace J, Mont MA, Delanois RE. Race Associated With Increased Complication Rates After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2220-2225. [PMID: 37172792 DOI: 10.1016/j.arth.2023.04.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications. METHODS A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients. RESULTS The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455). CONCLUSION Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.
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Affiliation(s)
- Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Christopher G Salib
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Zareef U, Paul RW, Sudah SY, Erickson BJ, Menendez ME. Influence of Race on Utilization and Outcomes in Shoulder Arthroplasty: A Systematic Review. JBJS Rev 2023; 11:01874474-202306000-00015. [PMID: 37335835 DOI: 10.2106/jbjs.rvw.23.00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Studies have shown that utilization and outcomes after shoulder arthroplasty vary by sociodemographic factors, highlighting disparities in care. This systematic review synthesized all available literature regarding the relationship between utilization and outcomes of shoulder arthroplasty and race/ethnicity. METHODS Studies were identified using PubMed, MEDLINE (through Ovid), and CINAHL databases. All English language studies of Level I through IV evidence that specifically evaluated utilization and/or outcomes of hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty by race and/or ethnicity were included. Outcomes of interest included rates of utilization, readmission, reoperation, revision, and complications. RESULTS Twenty-eight studies met inclusion criteria. Since the 1990s, Black and Hispanic patients have demonstrated a lower utilization rate of shoulder arthroplasty compared with White patients. Although utilization has increased among all racial groups throughout the present decade, the rate of increase is greater for White patients. These differences persist in both low-volume and high-volume centers and are independent of insurance status. Compared with White patients, Black patients have a longer postoperative length of stay after shoulder arthroplasty, worse preoperative and postoperative range of motion, a higher likelihood of 90-day emergency department visits, and a higher rate of postoperative complications including venous thromboembolism, pulmonary embolism, myocardial infarction, acute renal failure, and sepsis. Patient-reported outcomes, including the American Shoulder and Elbow Surgeon's score, did not differ between Black and White patients. Hispanics had a significantly lower revision risk compared with White patients. One-year mortality did not differ significantly between Asians, Black patients, White patients, and Hispanics. CONCLUSION Shoulder arthroplasty utilization and outcomes vary by race and ethnicity. These differences may be partly due to patient factors such as cultural beliefs, preoperative pathology, and access to care, as well as provider factors such as cultural competence and knowledge of health care disparities. LEVEL OF EVIDENCE Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Usman Zareef
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ryan W Paul
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Suleiman Y Sudah
- Department of Orthopaedic Surgery, Rutgers Health Monmouth Medical Center, Long Branch, New Jersey
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, New York, New York
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Upfill-Brown A, Paisner N, Sassoon A. Racial disparities in post-operative complications and discharge destination following total joints arthroplasty: a national database study. Arch Orthop Trauma Surg 2023; 143:2227-2233. [PMID: 35695924 PMCID: PMC10030399 DOI: 10.1007/s00402-022-04485-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 05/16/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this study was to explore race-based differences in 30-day complication rates following total joint arthroplasty (TJA) using a large national database. METHODS Patients undergoing primary, elective THA and TKA between 2012 and 2018 were retrospectively reviewed using the ACS-NSQIP. We compared Black and Hispanic patients with non-Hispanic White patients using multivariate statistical models adjusting for demographic, operative, and medical characteristics. RESULTS A total of 324,795 and 200,023 patients undergoing THA and TKA, respectively, were identified. After THA, compared to White patients, Black and Hispanic patients were more likely to be diagnosed with VTE (p < 0.001), receive a blood transfusion (p < 0.001), and to be discharged to an inpatient facility (p < 0.001). After TKA, compared to White patients, Black and Hispanic patients were more likely to experience a major complication (p < 0.001 and p = 0.008, respectively), be diagnosed with VTE (p < 0.001), and be discharged to a facility (p < 0.001). CONCLUSIONS Our findings indicate higher rates of VTE, blood transfusions, and discharge to an inpatient facility for Black and Hispanic patients when compared to White patients following TJA, though we are unable to comment on the etiology of these disparities. These results may contribute to a growing divide with respect to outcomes and access to TJA for these at-risk patient populations.
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Affiliation(s)
- Alex Upfill-Brown
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA
| | - Noah Paisner
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA
- Pacific Northwest University School of Health Sciences, Yakima, WA, USA
| | - Adam Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1225 15thSt, Suite 3145, Santa Monica, CA, 90404, USA.
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Dlott CC, Metcalfe T, Bahel A, Jain S, Donnelley CA, Kayani J, Wiznia DH. Characterizing the lack of diversity in musculoskeletal urgent care website content. BMC Health Serv Res 2023; 23:297. [PMID: 36978168 PMCID: PMC10053459 DOI: 10.1186/s12913-023-09270-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Musculoskeletal urgent care centers (MUCCs) are becoming an alternative to emergency departments for non-emergent orthopedic injuries as they can provide direct access to orthopedic specialty care. However, they tend to be located in more affluent geographies and are less likely to accept Medicaid insurance than general urgent care centers. MUCCs utilize websites to drive patients to their centers, and the content may influence patients' consumer behaviors and perceptions of the quality and accessibility of the MUCCs. Given that some MUCCs target insured patient populations, we evaluated the racial, gender, and body type diversity of website content for MUCCs. METHODS Our group conducted an online search to create a list of MUCCs in the United States. For each MUCC, we analyzed the content featured prominently on the website (above the fold). For each website, we analyzed the race, gender, and body type of the featured model(s). MUCCs were classified according to their affiliation (i.e. academic versus private) and region (i.e. Northeast versus South). We performed chi-squared and univariate logistic regression to investigate trends in MUCC website content. RESULTS We found that 14% (32/235) of website graphics featured individuals from multiple racial groups, 57% (135/235) of graphics featured women, and 2% (5/235) of graphics featured overweight or obese individuals. Multiracial presence in website graphics was associated with the presence of women on the websites and Medicaid acceptance. CONCLUSION MUCC website content has the potential to impact patients' perceptions of medical providers and the medical care they receive. Most MUCC websites lack diversity based on race and body type. The lack of diversity in website content at MUCCs may introduce further disparities in access to orthopedic care.
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Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA.
| | - Tanner Metcalfe
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Anchal Bahel
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Sanjana Jain
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Claire A Donnelley
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Jehanzeb Kayani
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Daniel H Wiznia
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
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Rudisill SS, Varady NH, Birir A, Goodman SM, Parks ML, Amen TB. Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:171-187.e18. [PMID: 35985539 DOI: 10.1016/j.arth.2022.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Samuel S Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Rush Medical College of Rush University, Chicago, Illinois
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Aseal Birir
- Harvard Medical School, Boston, Massachusetts
| | - Susan M Goodman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael L Parks
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Hwang A, Zhang L, Ramirez G, Maloney M, Voloshin I, Thirukumaran C. Black Race, Hispanic Ethnicity, and Medicaid Insurance Are Associated With Lower Rates of Rotator Cuff Repair in New York State. Arthroscopy 2022; 38:3001-3010.e2. [PMID: 35817374 DOI: 10.1016/j.arthro.2022.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair. METHODS A retrospective review of the Statewide Planning and Research Cooperative System Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months of follow-up. Bivariate analysis using χ2 tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair. RESULTS A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (adjusted odds ratio [aOR] 0.78; 95% confidence interval [CI] 0.69-0.87; P < .001), Hispanic/Latino ethnicity (aOR 0.91; 95% CI 0.85-0.97); P = .004), and Medicaid (aOR 0.75; 95% CI 0.70-0.80; P < .001), or other government insurance (aOR 0.82; 95% CI 0.78-0.86; P < .001) were independently associated with lower rates of rotator cuff repair. Male sex (aOR 1.18; 95% CI 1.14-1.22; P < .001), Asian race (aOR 1.27; 95% CI 1.00-1.62; P = .048), workers' compensation insurance (aOR 1.12; 95% CI 1.07-1.18; P < .001), and greater home ZIP code income quartile (aOR 1.19; 95% CI 1.09-1.30; P < .001) were independently associated with greater rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology. CONCLUSIONS In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017 to 2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home ZIP code income quartile. CLINICAL RELEVANCE This study reports disparities in the use of rotator cuff repair for individuals with rotator cuff pathology.
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Affiliation(s)
- Alan Hwang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A..
| | - Linda Zhang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Gabriel Ramirez
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael Maloney
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Ilya Voloshin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Caroline Thirukumaran
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Association Between Race/Ethnicity and Total Joint Arthroplasty Utilization in a Universally Insured Population. J Am Acad Orthop Surg 2022; 30:e1348-e1357. [PMID: 36044283 DOI: 10.5435/jaaos-d-22-00146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Barbera JP, Raymond HE, Zubizarreta N, Poeran J, Chen DD, Hayden BL, Moucha CS. Racial Differences in Manipulation Under Anesthesia Rates Following Total Knee Arthroplasty. J Arthroplasty 2022; 37:1865-1869. [PMID: 35398226 DOI: 10.1016/j.arth.2022.03.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the extensive literature on racial disparities in care and outcomes after total knee arthroplasty (TKA), data on manipulation under anesthesia (MUA) is lacking. We aimed to determine (1) the relationship between race and rate of (and time to) MUA after TKA, and (2) annual trends in racial differences in MUA from 2013 to 2018. METHODS This retrospective cohort study (using 2013-2018 Medicare Limited Data Set claims data) included 836,054 primary TKA patients. The primary outcome was MUA <1 year after TKA; time from TKA to MUA in days was also recorded. A mixed-effects multivariable model measured the association between race (White, Black, Other) and odds of MUA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. A Cochran Armitage Trend test was conducted to assess MUA trends over time, stratified by race. RESULTS MUA after TKA occurred in 1.7%, 3.2% and 2.1% of White, Black, and Other race categories, respectively (SMD = 0.07). After adjustment for covariates, (Black vs White) patients had increased odds of requiring an MUA after TKA: odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.86-2.10, P < .0001. Moreover, White (compared to Black) patients had significantly shorter time to MUA after TKA: 60 days (interquartile range [IQR] 46-88) versus 64 days (interquartile range [IQR] 47-96); P < .0001. These disparities persisted from 2013 through 2018. CONCLUSION Continued racial differences exist for rates and timing of MUA following TKA signifying the continued need for efforts aimed toward understanding and eliminating inequalities that exist in total joint arthroplasty (TJA) care.
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Affiliation(s)
- Joseph P Barbera
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Hayley E Raymond
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Nicole Zubizarreta
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Darwin D Chen
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
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Wu M, Case A, Kim BI, Cochrane NH, Nagy GA, Bolognesi MP, Seyler TM. Racial and Ethnic Disparities in the Imaging Workup and Treatment of Knee and Hip Osteoarthritis. J Arthroplasty 2022; 37:S753-S760.e2. [PMID: 35151805 DOI: 10.1016/j.arth.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is limited evidence on sociodemographic differences in osteoarthritis management, particularly in non-African American (AA) minorities. We sought to identify differences in imaging modalities, administration of intra-articular injections, and total joint arthroplasty (TJA) between racial/ethnic groups. METHODS We retrospectively reviewed patients presenting to outpatient clinics with a diagnosis of hip or knee osteoarthritis from January 2013 to March 2020 at a tertiary center. Univariate analyses compared differences between groups. Multivariate logistic regression analyses determined sociodemographic predictors of imaging workup and treatment. RESULTS In total, 105,873 patients were included. There were 74,769 (70.6%) Caucasian, 27,117 (25.6%) AA, 1,878 (1.8%) Hispanic, 1,479 (1.4%) Asian, and 630 (0.6%) Native American patients. Multivariate analyses demonstrated that AAs had decreased odds of undergoing a knee magnetic resonance imaging (odds ratio [OR] 0.77, P < .001) or injection (OR 0.94, P = .006). Asian patients had lower odds of receiving any hip X-ray (OR 0.72, P = .047) or knee injection (OR 0.83, P = .017). AA (total knee arthroplasty [TKA]: OR 0.51, P < .001; total hip arthroplasty [THA]: OR 0.57, P < .001), Hispanic (TKA: OR 0.69, P = .003; THA: OR 0.60, P = .006), and Asian (TKA: OR 0.73, P = .010; THA: OR 0.56, P = .010) patients had lower odds of undergoing TJA compared to Caucasians. We found that higher income quartiles had greater odds of receiving a magnetic resonance imaging and TJA, males had lower odds of receiving injections and greater odds of undergoing TJA, and Medicaid and self-pay patients had lower odds of undergoing TJA (P < .05). CONCLUSION After adjusting for sociodemographic factors, we found disparities in the imaging, administration of injections, and/or arthroplasty for AA, Asian, and Hispanic patients. Insurance status, income, and gender were also associated with imaging and treatments performed in managing hip and knee osteoarthritis.
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Affiliation(s)
- Mark Wu
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ayden Case
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Billy I Kim
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Gabriela A Nagy
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Cwalina TB, Jella TK, Manyak GA, Kuo A, Kamath AF. Is Our Science Representative? A Systematic Review of Racial and Ethnic Diversity in Orthopaedic Clinical Trials from 2000 to 2020. Clin Orthop Relat Res 2022; 480:848-858. [PMID: 34855650 PMCID: PMC9007212 DOI: 10.1097/corr.0000000000002050] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND A lack of racial and ethnic representation in clinical trials may limit the generalizability of the orthopaedic evidence base as it applies to patients in underrepresented minority populations and perpetuate existing disparities in use, complications, or functional outcomes. Although some commentators have implied the need for mandatory race or ethnicity reporting across all orthopaedic trials, the usefulness of race or ethnic reporting likely depends on the specific topic, prior evidence of disparities, and individualized study hypotheses. QUESTIONS/PURPOSES In a systematic review, we asked: (1) What proportion of orthopaedic clinical trials report race or ethnicity data, and of studies that do, how many report data regarding social covariates or genomic testing? (2) What trends and associations exist for racial and ethnic reporting among these trials between 2000 and 2020? (3) What is the racial or ethnic representation of United States trial participants compared with that reported in the United States Census? METHODS We performed a systematic review of randomized controlled trials with human participants published in three leading general-interest orthopaedic journals that focus on clinical research: The Journal of Bone and Joint Surgery, American Volume; Clinical Orthopaedics and Related Research; and Osteoarthritis and Cartilage. We searched the PubMed and Embase databases using the following inclusion criteria: English-language studies, human studies, randomized controlled trials, publication date from 2000 to 2020, and published in Clinical Orthopaedics and Related Research; The Journal of Bone and Joint Surgery, American Volume; or Osteoarthritis and Cartilage. Primary outcome measures included whether studies reported participant race or ethnicity, other social covariates (insurance status, housing or homelessness, education and literacy, transportation, income and employment, and food security and nutrition), and genomic testing. The secondary outcome measure was the racial and ethnic categorical distribution of the trial participants included in the studies reporting race or ethnicity. From our search, 1043 randomized controlled trials with 184,643 enrolled patients met the inclusion criteria. Among these studies, 21% (223 of 1043) had a small (< 50) sample size, 56% (581 of 1043) had a medium (50 to 200) sample size, and 23% (239 of 1043) had a large (> 200) sample size. Fourteen percent (141 of 1043) were based in the Northeast United States, 9.2% (96 of 1043) were in the Midwest, 4.7% (49 of 1043) were in the West, 7.2% (75 of 1043) were in the South, and 65% (682 of 1043) were outside the United States. We calculated the overall proportion of studies meeting the inclusion criteria that reported race or ethnicity. Then among the subset of studies reporting race or ethnicity, we determined the overall rate and distribution of social covariates and genomic testing reporting. We calculated the proportion of studies reporting race or ethnicity that also reported a difference in outcome by race or ethnicity. We calculated the proportion of studies reporting race or ethnicity by each year in the study period. We also calculated the proportions and 95% CIs of individual patients in each racial or ethnic category of the studies meeting the inclusion criteria. RESULTS During the study period (2000 to 2020), 8.5% (89 of 1043) of studies reported race or ethnicity. Of the trials reporting this factor, 4.5% (four of 89) reported insurance status, 15% (13 of 89) reported income, 4.5% (four of 89) reported housing or homelessness, 18% (16 of 89) reported education and literacy, 0% (0 of 89) reported transportation, and 2.2% (two of 89) reported food security or nutrition of trial participants. Seventy-eight percent (69 of 89) of trials reported no social covariates, while 22% (20 of 89) reported at least one. However, 0% (0 of 89) of trials reported genomic testing. Additionally, 5.6% (five of 89) of these trials reported a difference in outcomes by race or ethnicity. The proportion of studies reporting race or ethnicity increased, on average, by 0.6% annually (95% CI 0.2% to 1.0%; p = 0.02). After controlling for potentially confounding variables such as funding source, we found that studies with an increased sample size were more likely to report data by race or ethnicity; location in North America overall, Europe, Asia, and Australia or New Zealand (compared with the Northeast United States) were less likely to; and specialty-topic studies (compared with general orthopaedics research) were less likely to. Our sample of United States trials contained 18.9% more white participants than that reported in the United States Census (95% CI 18.4% to 19.4%; p < 0.001), 5.0% fewer Black participants (95% CI 4.6% to 5.3%; p < 0.001), 17.0% fewer Hispanic participants (95% CI 16.8% to 17.1%; p < 0.001), 5.3% fewer Asian participants (95% CI 5.2% to 5.4%; p < 0.001), and 7.5% more participants from other groups (95% CI 7.2% to 7.9%; p < 0.001). CONCLUSION Reporting of race or ethnicity data in orthopaedic clinical trials is low compared with other medical fields, although the proportion of diseases warranting this reporting might be lower in orthopaedics. CLINICAL RELEVANCE Investigators should initiate discussions about race and ethnicity reporting in the early stages of clinical trial development by surveying available published evidence for relevant health disparities, social determinants, and, when warranted, genomic risk factors. The decision to include or exclude race and ethnicity data in study protocols should be based on specific hypotheses, necessary statistical power, and an appreciation for unmeasured confounding. Future studies should evaluate cost-efficient mechanisms for obtaining baseline social covariate data and investigate researcher perspectives on current administrative workflows and decision-making algorithms for race and ethnicity reporting.
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Affiliation(s)
- Thomas B. Cwalina
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tarun K. Jella
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Grigory A. Manyak
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andy Kuo
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Atul F. Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Rev 2022; 10:01874474-202203000-00003. [PMID: 35231001 DOI: 10.2106/jbjs.rvw.21.00161] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Paul M Alvarez
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John F McKeon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew I Spitzer
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Matthew Pigott
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mengnai Li
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sravya P Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Abstract
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.
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Affiliation(s)
- Susan Salmond
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| | - Caroline Dorsen
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
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19
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Resad Ferati S, Parisien RL, Joslin P, Knapp B, Li X, Curry EJ. Socioeconomic Status Impacts Access to Orthopaedic Specialty Care. JBJS Rev 2022; 10:01874474-202202000-00007. [PMID: 35171876 DOI: 10.2106/jbjs.rvw.21.00139] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
» Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care. » Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States. » Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes. » Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.
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Affiliation(s)
- Sehar Resad Ferati
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Patrick Joslin
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Brock Knapp
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Emily J Curry
- Boston University School of Public Health, Boston, Massachusetts
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Hartnett DA, Brodeur PG, Kosinski LR, Cruz AI, Gil JA, Cohen EM. Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty. J Arthroplasty 2022; 37:213-218.e1. [PMID: 34748913 DOI: 10.1016/j.arth.2021.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/02/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis. METHODS From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA. RESULTS Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001). CONCLUSION THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.
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Affiliation(s)
- Davis A Hartnett
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Peter G Brodeur
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Lindsay R Kosinski
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric M Cohen
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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21
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Usiskin I, Misra D. Racial Disparities in Elective Total Joint Arthroplasty for Osteoarthritis. ACR Open Rheumatol 2022; 4:306-311. [PMID: 34989176 PMCID: PMC8992460 DOI: 10.1002/acr2.11399] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/27/2022] Open
Abstract
Total joint arthroplasty (TJA) is an effective elective surgical procedure for knee and hip osteoarthritis (OA), yet racial disparities in the use of and outcomes from TJA have been recognized. Racial minority individuals are less willing to undergo TJA, demonstrate worse surgical and functional outcomes, and are more likely to undergo surgery at a low‐procedure‐volume center. In this systematic review, we summarize evidence to date on racial disparities in TJA and discuss potential factors that may underlie this gap in care for patients with OA.
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Affiliation(s)
- Ilana Usiskin
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Devyani Misra
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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22
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Atarere J, Agudile E, Orhurhu V, Agudile UM, Sorescu G, Suleiman ZA, Weaver MJ, Von Keudell A. Racial and Socioeconomic Disparities in the Utilization of TKA Among Patients with Posttraumatic Knee Osteoarthritis. JB JS Open Access 2022; 7:JBJSOA-D-22-00017. [PMID: 36128256 PMCID: PMC9478297 DOI: 10.2106/jbjs.oa.22.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Advanced posttraumatic osteoarthritis (PTOA) of the knee is a cause of substantial disability, particularly in younger individuals, and the treatment of choice is total knee arthroplasty (TKA). Racial and socioeconomic disparities exist in the use of TKA, but, to our knowledge, there have been no studies examining these disparities among patients with PTOA.
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Affiliation(s)
- Joseph Atarere
- Department of Biostatistics and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
- Email for corresponding author:
| | - Emeka Agudile
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Internal Medicine, Carney Hospital, Boston, Massachusetts
| | - Vwaire Orhurhu
- Department of Anesthesia, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ukamaka M. Agudile
- Department of Family Medicine, Federal Medical Center, Gusau, Zamfara, Nigeria
| | - George Sorescu
- Department of Internal Medicine, Lemuel Shattuck Hospital, Boston, Massachusetts
| | - Zakari Aliyu Suleiman
- Department of Anesthesia, University of Ilorin Teaching Hospital, Ilorin, Ondo, Nigeria
| | - Michael J. Weaver
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arvind Von Keudell
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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23
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Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center. OTA Int 2021; 4:e155. [PMID: 34765905 PMCID: PMC8575413 DOI: 10.1097/oi9.0000000000000155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 08/31/2021] [Indexed: 12/24/2022]
Abstract
Objectives: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. Design: Retrospective chart review. Setting: Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. Intervention: Virtual visits utilizing the Doxy.me platform. Main Outcome Measures: Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”). Methods: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”). Results: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). Conclusion: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.
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24
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Okike K. My Grandmother's Knees: A Call for Research on Strategies to Address Racial and Ethnic Disparities in Orthopaedic Surgery. J Bone Joint Surg Am 2021; 103:1961-1962. [PMID: 34730562 DOI: 10.2106/jbjs.21.01081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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25
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Disparities across Diverse Populations in the Health and Treatment of Patients with Osteoarthritis. Healthcare (Basel) 2021; 9:healthcare9111421. [PMID: 34828468 PMCID: PMC8619799 DOI: 10.3390/healthcare9111421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
The study of disparities across diverse populations regarding the health and treatment of patients with osteoarthritis (OA) is recognized as a priority for investigation and action by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the American Academy of Orthopedic Surgeons (AAOS). OA is a common condition that increases with age, but with prevalence generally similar across racial and ethnic groups. However, disparities in the treatment of OA among racial, ethnic, and socioeconomic groups are well-documented and continue to rise and persist. The reasons are complex, likely involving a combination of patient, provider, and healthcare system factors. Treatment disparities among these different populations have an impact on clinical outcomes, healthcare, and productivity, and are projected to increase significantly with the growing diversity of the United States population. The aim of this short review is to summarize studies of racial, ethnic, and socioeconomic disparities among patients with OA in the United States, with a focus on prevalence, treatment utilization, and clinical and economic outcomes.
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26
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Best MJ, Aziz KT, McFarland EG, Martin SD, Rue JPH, Srikumaran U. Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2021; 30:1844-1850. [PMID: 33220419 DOI: 10.1016/j.jse.2020.10.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The most comprehensive health care policy changes aimed at reducing racial disparities were implemented in 2011 and continue today. It is unknown if these initiatives have led to a decrease in racial differences among patients undergoing total shoulder arthroplasty. The purpose of this study is to examine racial differences in procedural rates, complications, and mortality in patients undergoing total shoulder arthroplasty. METHODS National rates of utilization of primary anatomic (TSA) and reverse total shoulder arthroplasty (RTSA) were analyzed from 2012 to 2017. Population-adjusted and gender-adjusted procedural rates were trended over time and standardized based on insurance status. Multivariable logistic regression was used to determine racial differences in complications and mortality. RESULTS In 2012, the incidence of TSA and RTSA among white patients was 18.7/100,000 compared to 5.1/100,000 among black patients (difference: 13.6/100,000) and increased to 36.9/100,000 in white patients and 10.8/100,000 in black patients in 2017 (difference: 26.1/100,000). This equated to an increase in the race disparity by 12.5/100,000 over the study period. Blacks underwent lower rates of TSA and RTSA than whites regardless of insurance status. Black patients had a longer length of hospital stay and a higher rate of discharge to facility. Black patients had increased odds of complications, including acute myocardial infarction (odds ratio [OR] 1.43), pulmonary embolism (OR 1.97), acute renal failure (OR 1.40), sepsis (OR 1.68), and surgical site infection (OR 2.19). Black patients had increased odds of mortality compared with white patients (OR 2.88). CONCLUSION Racial disparities in patients undergoing TSA and RTSA are worsening over time. Black patients undergo TSA and RTSA at lower rates than white patients regardless of insurance status and have increased odds of complications and mortality. Improved initiatives are needed to reduce these racial disparities and further research is warranted to understand their root causes.
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Affiliation(s)
- Matthew J Best
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Keith T Aziz
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward G McFarland
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John-Paul H Rue
- Department of Orthopaedics, Mercy Medical Center, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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The Impact of Race and Socioeconomic Status on Total Joint Arthroplasty Care. J Arthroplasty 2021; 36:2729-2733. [PMID: 33773863 DOI: 10.1016/j.arth.2021.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Racial minorities and patients from lower socioeconomic backgrounds are less likely to undergo total joint arthroplasty (TJA) for degenerative joint disease (DJD). However, when these patients do present for care, little is known about the overall severity of DJD and surgical wait times. METHODS A retrospective cohort of 407 patients (131 black and 276 white) who presented to an arthroplasty clinic and went on to receive TJA was established. Severity of osteoarthritis was assessed radiographically via Kellgren-Lawrence (KL) grade. Preoperative Knee Society Score (KSS) and Harris Hip Score (HHS) were used to measure joint pain and function. Multivariate regression modeling and analysis of covariance were used to examine racial and socioeconomic differences in KL grade, KSS, HHS, and time to surgery. RESULTS Black patients presented with significantly greater KL scores than white patients (P = .046, odds ratio = 1.65, 95% confidence interval [1.01, 2.70]). In contrast, there were no statistically significant racial differences in the mean preoperative KSS (P = .61) or HHS (P = .69). Black patients were also found to wait, on average, 35% longer for TJA (P = .03, hazard ratio = 1.35, 95% confidence interval [1.04, 1.75]). Low income was associated with higher KL grade (P = .002), lower KSS (P = .07), and lower HHS (P = .001). CONCLUSION Despite presenting with more advanced osteoarthritis, black patients reported similar levels of joint dysfunction and had longer surgical wait times when compared with white patients. Lower socioeconomic status was similarly associated with more severe DJD.
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28
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Salehi O, Vega EA, Lathan C, James D, Kozyreva O, Alarcon SV, Kutlu OC, Herrick B, Conrad C. Race, Age, Gender, and Insurance Status: A Comparative Analysis of Access to and Quality of Gastrointestinal Cancer Care. J Gastrointest Surg 2021; 25:2152-2162. [PMID: 34027580 DOI: 10.1007/s11605-021-05038-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Socioeconomics, demographics, and insurance status play roles in healthcare access. Considering the limited resources available, understanding the relative impact of disparities helps prioritize programs designed to overcome them. This study evaluates gastrointestinal cancer care disparity by comparing the impact of different patient factors across oncologic care metrices. METHODS A multi-institutional prospectively maintained cancer database was reviewed retrospectively for gastrointestinal cancers (esophagus, stomach, liver, pancreas, colorectal, and hepato-pancreato-biliary) from 2007 to 2017 to assess quality of care provided. Quality of care was defined by clinical course following national guidelines for the respective cancer. This included surgical intervention, chemotherapy, palliative care, and minimal delay to treatment/diagnosis. Logistic regression was used to adjust for confounders and identify factors associated with quality of care. Kaplan-Meier survival curves were compared using log-rank test. RESULTS One thousand seventy-two patients were identified. Survival improved in patients with private insurance compared to government-funded options [median overall survival (mOS) 57.8 vs. 21.2 months; P < .001]. Private insurance also correlated with earlier stage at diagnosis [stages I-II = 50.9% vs. 37.5%, stages III-IV = 37.7% vs. 49.1%, P < .001], increased chemotherapy use [44.2% vs. 37.1%, P < .001], and more surgical intervention [62.4% vs. 48.8%, P < .001]. Outcomes were inferior for Black Americans, including trend towards lower rate of surgical treatment [42% vs. 54%, P = .058] and worse survival in private insurance carriers [mOS 7.8 vs. 57.8 months, P = .021] and those with early stage disease [mOS 39.2 vs. 81.5 months, P = .045] compared to White counterparts. CONCLUSIONS Insurance status has the strongest impact on the quality of gastrointestinal oncologic care with negative synergistic negative effect of race for Black Americans. While governmental programs aim to improve equality of care, there remains significant disparity compared to private insurance. Moreover, private insurance doesn't correct disparity for Black Americans, suggesting the need to address racial imbalances in cancer care.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Christopher Lathan
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Daria James
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Sylvia V Alarcon
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Beth Herrick
- Department of Radiation Oncology, St. Elizabeth's Medical Center, & University of Massachusetts School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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29
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Xiong G, Greene NE, Lightsey HM, Crawford AM, Striano BM, Simpson AK, Schoenfeld AJ. Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status. Clin Orthop Relat Res 2021; 479:1417-1425. [PMID: 33982979 PMCID: PMC8208394 DOI: 10.1097/corr.0000000000001775] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Healthcare disparities are well documented across multiple subspecialties in orthopaedics. The widespread implementation of telemedicine risks worsening these disparities if not carefully executed, despite original assumptions that telemedicine improves overall access to care. Telemedicine also poses unique challenges such as potential language or technological barriers that may alter previously described patterns in orthopaedic disparities. QUESTIONS/PURPOSES Are the proportions of patients who use telemedicine across orthopaedic services different among (1) racial and ethnic minorities, (2) non-English speakers, and (3) patients insured through Medicaid during a 10-week period after the implementation of telemedicine in our healthcare system compared with in-person visits during a similar time period in 2019? METHODS This was a retrospective comparative study using electronic medical record data to compare new patients establishing orthopaedic care via outpatient telemedicine at two academic urban medical centers between March 2020 and May 2020 with new orthopaedic patients during the same 10-week period in 2019. A total of 11,056 patients were included for analysis, with 1760 in the virtual group and 9296 in the control group. Unadjusted analyses demonstrated patients in the virtual group were younger (median age 57 years versus 59 years; p < 0.001), but there were no differences with regard to gender (56% female versus 56% female; p = 0.66). We used self-reported race or ethnicity as our primary independent variable, with primary language and insurance status considered secondarily. Unadjusted and multivariable adjusted analyses were performed for our primary and secondary predictors using logistic regression. We also assessed interactions between race or ethnicity, primary language, and insurance type. RESULTS After adjusting for age, gender, subspecialty, insurance, and median household income, we found that patients who were Hispanic (odds ratio 0.59 [95% confidence interval 0.39 to 0.91]; p = 0.02) or Asian were less likely (OR 0.73 [95% CI 0.53 to 0.99]; p = 0.04) to be seen through telemedicine than were patients who were white. After controlling for confounding variables, we also found that speakers of languages other than English or Spanish were less likely to have a telemedicine visit than were people whose primary language was English (OR 0.34 [95% CI 0.18 to 0.65]; p = 0.001), and that patients insured through Medicaid were less likely to be seen via telemedicine than were patients who were privately insured (OR 0.83 [95% CI 0.69 to 0.98]; p = 0.03). CONCLUSION Despite initial promises that telemedicine would help to bridge gaps in healthcare, our results demonstrate disparities in orthopaedic telemedicine use based on race or ethnicity, language, and insurance type. The telemedicine group was slightly younger, which we do not believe undermines the findings. As healthcare moves toward increased telemedicine use, we suggest several approaches to ensure that patients of certain racial, ethnic, or language groups do not experience disparate barriers to care. These might include individual patient- or provider-level approaches like expanded telemedicine schedules to accommodate weekends and evenings, institutional investment in culturally conscious outreach materials such as advertisements on community transport systems, or government-level provisions such as reimbursement for telephone-only encounters. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Grace Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Nattaly E Greene
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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30
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022] Open
Abstract
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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Best MJ, McFarland EG, Thakkar SC, Srikumaran U. Racial Disparities in the Use of Surgical Procedures in the US. JAMA Surg 2021; 156:274-281. [PMID: 33439237 DOI: 10.1001/jamasurg.2020.6257] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Importance The largest US federal action plan to date for reducing racial disparities in health care was implemented in 2011 and continues today. It is not known whether this program, along with other initiatives, is associated with a decrease in racial disparities in the use of major surgical procedures in the US. Objective To analyze whether national initiatives are associated with improvement in racial disparities between White and Black patients in the use of surgical procedures in the US. Design, Setting, and Participants In this case-control study, the national rates of use for 9 major surgical procedures previously shown to have racial disparities in rates of performance between White and Black adult patients (including angioplasty, spinal fusion, carotid endarterectomy, appendectomy, colorectal resection, coronary artery bypass grafting, total hip arthroplasty, total knee arthroplasty, and heart valve replacement) were analyzed from January 1, 2012, through December 31, 2017. Data analysis was conducted from May 1 to June 30, 2020. Population- and sex-adjusted procedural rates during the study period were examined and standardized based on all-payer insurance status. Racial changes were further analyzed by US census division and hospital teaching status for 4 selected procedures: coronary artery bypass grafting, carotid endarterectomy, total hip arthroplasty, and heart valve replacement. Main Outcomes and Measures Population- and race-adjusted procedural rates by year, US census division, hospital teaching status, and insurance status. Results This study included national inpatient data from 2012 to 2017. In 2012, the national incidence rate of all 9 major surgical procedures was higher in White than in Black individuals. For example, the incidence rate of total knee arthroplasty in 2012 for White males was 184.8 per 100 000 persons and for Black males was 79.8 per 100 000 persons. By 2017, these racial disparities persisted for all 9 procedures analyzed. For example, the incidence rate of total knee arthroplasty in 2017 for White males was 220.5 per 100 000 persons and for Black males was 95.6 per 100 000 persons. Although the disparity gap between White and Black patients narrowed for angioplasty (-20.1 per 100 000 persons in males, -4.2 per 100 000 persons in females), spinal fusion (-7.7 per 100 000 persons in males, -15.0 per 100 000 persons in females), carotid endarterectomy (-4.3 per 100 000 persons in males, -4.6 per 100 000 persons in females), appendectomy (-12.3 per 100 000 persons in males, -12.2 per 100 000 persons in females), and colorectal resection (-9.0 per 100 000 persons in males, -12.7 per 100 000 persons in females), the disparity remained constant for coronary artery bypass grafting and widened for 3 procedures, total hip arthroplasty (11.6 per 100 000 persons in males, 20.8 per 100 000 in females), total knee arthroplasty (19.9 per 100 000 persons in males, 12.0 per 100 000 persons in females), and heart valve replacement(12.4 per 100 000 persons in males, 9.2 per 100 000 persons in females). In 2017, racial differences persisted in all US census divisions and in both urban teaching and urban nonteaching hospitals. When rates were adjusted based on insurance status, Black patients with Medicare, Medicaid, and private insurance underwent lower rates of all procedures analyzed compared with White patients. For example, rate of spinal fusion in Black patients was 70.2% of the rate in White patients with Medicare, 56.5% to that of White patients with Medicaid, and 61.2% to that of White patients with private insurance. Conclusions and Relevance Results of this study suggest that despite national initiatives, racial disparities have persisted for all analyzed procedures and worsened for one-third of the analyzed procedures. These disparities were evident regardless of US census division, hospital teaching status, or insurance status. Renewed initiatives to help diminish racial disparities and improve health care equality are warranted.
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Affiliation(s)
- Matthew J Best
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward G McFarland
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Savyasachi C Thakkar
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Importance Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA. Observations Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing. Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury. Persons with OA have more comorbidities and are more sedentary than those without OA. The reduced physical activity leads to a 20% higher age-adjusted mortality. Several physical examination findings are useful diagnostically, including bony enlargement in knee OA and pain elicited with internal hip rotation in hip OA. Radiographic indicators include marginal osteophytes and joint space narrowing. The cornerstones of OA management include exercises, weight loss if appropriate, and education-complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided. Clinical trials have shown promising results for compounds that arrest structural progression (eg, cathepsin K inhibitors, Wnt inhibitors, anabolic growth factors) or reduce OA pain (eg, nerve growth factor inhibitors). Persons with advanced symptoms and structural damage are candidates for total joint replacement. Racial and ethnic disparities persist in the use and outcomes of joint replacement. Conclusions and Relevance Hip and knee OA are highly prevalent and disabling. Education, exercise and weight loss are cornerstones of management, complemented by NSAIDs (for patients who are candidates), corticosteroid injections, and several adjunctive medications. For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain.
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Affiliation(s)
- Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, MA, USA
| | - Kaetlyn R. Arant
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard F. Loeser
- Division of Rheumatology, Allergy and Immunology and the Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
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Abstract
This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.
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Affiliation(s)
- Angel M Reyes
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, BWH Orthopaedics, OrACORe Group, 75 Francis Street, BTM Suite 5016, Boston, MA 02115, USA.
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, BWH Orthopaedics, OrACORe Group, 75 Francis Street, BTM Suite 5016, Boston, MA 02115, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Hettrich CM, Zacharias A, Ortiz SF, Westgate P, Wolf BR, Jacobs C. Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group. J Shoulder Elbow Surg 2021; 30:229-236. [PMID: 33166646 DOI: 10.1016/j.jse.2020.09.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. METHODS Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. RESULTS Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. CONCLUSION We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.
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Affiliation(s)
- Carolyn M Hettrich
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Anthony Zacharias
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA.
| | - Shannon F Ortiz
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Philip Westgate
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Brian R Wolf
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Cale Jacobs
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
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Vina ER, Quinones C, Hausmann LRM, Ibrahim SA, Kwoh CK. Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis. J Rheumatol 2021; 48:1863-1870. [PMID: 33452165 DOI: 10.3899/jrheum.201133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA. METHODS A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02). CONCLUSION Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.
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Affiliation(s)
- Ernest R Vina
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Cristian Quinones
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Leslie R M Hausmann
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Said A Ibrahim
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - C Kent Kwoh
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
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Thirukumaran CP, Cai X, Glance LG, Kim Y, Ricciardi BF, Fiscella KA, Li Y. Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017. J Bone Joint Surg Am 2020; 102:2120-2128. [PMID: 33079898 PMCID: PMC8190867 DOI: 10.2106/jbjs.20.00246] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.
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Affiliation(s)
- Caroline P Thirukumaran
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Xueya Cai
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Laurent G Glance
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
| | - Benjamin F Ricciardi
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kevin A Fiscella
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Yue Li
- Departments of Orthopaedics (C.P.T. and B.F.R.), Public Health Sciences (C.P.T., L.G.G., Y.K., K.A.F., and Y.L.), Biostatistics and Computational Biology (X.C.), Anesthesiology and Perioperative Medicine (L.G.G.), and Family Medicine (K.A.F.), University of Rochester, Rochester, New York
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Ghoshal M, Shapiro H, Todd K, Schatman ME. Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards. J Pain Res 2020; 13:2825-2836. [PMID: 33192090 PMCID: PMC7654542 DOI: 10.2147/jpr.s287314] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
| | - Hannah Shapiro
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts, USA
| | - Knox Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center Houston, Texas, USA
| | - Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, Massachusetts, USA
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Williams JN, Ford CL, Morse M, Feldman CH. Racial Disparities in Rheumatology Through the Lens of Critical Race Theory. Rheum Dis Clin North Am 2020; 46:605-612. [PMID: 32981638 DOI: 10.1016/j.rdc.2020.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
According to critical race theory (CRT), racism is ubiquitous in society. In the field of medicine, systems of racism are subtly interwoven with patient care, medical education, and medical research. Public health critical race praxis (PHCRP) is a tool that allows researchers to apply CRT to research. This article discusses the application of CRT and PHCRP to 3 race-related misconceptions in rheumatology: (1) giant cell arteritis is rare in non-White populations; (2) Black patients are less likely to undergo knee replacement because of patient preference; and (3) HLA-B*5801 screening should only be performed for patients of Asian descent.
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Affiliation(s)
- Jessica N Williams
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Chandra L Ford
- Department of Community Health Sciences, Jonathan & Karin Fielding School of Public Health, University of California at Los Angeles, Box 951772, 650 Charles East Young Drive, South, Los Angeles, CA 90095-1772, USA
| | - Michelle Morse
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Candace H Feldman
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Office #6016P, Boston, MA 02115, USA
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Venugopal V, Gronbeck C, Harvey L, Patel AP, Harrington MA, Halawi MJ. Time Trends in Perioperative Characteristics and Health Outcomes in Hispanic Patients Undergoing Primary Total Knee Arthroplasty. J Racial Ethn Health Disparities 2020; 8:1475-1481. [DOI: 10.1007/s40615-020-00910-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/23/2022]
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Vina ER, Quinones C. Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care. Rheum Dis Clin North Am 2020; 47:83-96. [PMID: 34042056 DOI: 10.1016/j.rdc.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.
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Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA.
| | - Cristian Quinones
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA
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Gronbeck C, Cusano A, Cardenas JM, Harrington MA, Halawi MJ. Primary Total Hip Arthroplasty in Hispanic/Latino Patients: An Updated Nationwide Analysis of Length of Stay, 30-Day Outcomes, and Risk Factors. Arthroplast Today 2020; 6:721-725. [PMID: 32923557 PMCID: PMC7475048 DOI: 10.1016/j.artd.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
| | - Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Justin M Cardenas
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
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Johnson AJ, Sibille KT, Cardoso J, Terry EL, Powell-Roach KL, Goodin B, Staud R, Redden D, Fillingim RB, Booker SQ. Patterns and Correlates of Self-Management Strategies for Osteoarthritis-Related Pain Among Older Non-Hispanic Black and Non-Hispanic White Adults. Arthritis Care Res (Hoboken) 2020; 73:1648-1658. [PMID: 32741127 DOI: 10.1002/acr.24396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Knee osteoarthritis (OA) is a leading source of pain and disability among older adults. Self-management (SM) strategies are recommended to manage OA symptoms. Sociodemographic and clinical characteristics, along with other factors, may influence SM utilization rate. This study sought to examine the prevalence and correlates of SM use for pain among non-Hispanic Black patients (NHB) and non-Hispanic White patients (NHW) older adults with or at risk for knee OA. METHODS A secondary data analysis was conducted on the Understanding Pain and Limitations in Osteoarthritic Disease multisite observational study, which included NHB (n = 104) and NHW (n = 98) community-dwelling older adults with or at risk for knee OA. Participants completed measures of sociodemographics, pain SM use, coping, and clinical and experimental pain. RESULTS Clinical and experimental pain were significantly greater among NHBs compared to NHWs. There were no significant differences in use of total SM by ethnicity/race. Interestingly, multiple linear regression revealed that clinical and experimental pain indices, as well as coping, number of pain sites, age, and sex were differentially associated with total SM use between NHBs and NHWs. There were significant ethnicity/race by type of pain management interaction effects for pain measures. CONCLUSION SM is common among older adults with or at risk for knee OA pain, and the prevalence of SM does not differ by ethnicity/race, but many guideline-recommended interventions for OA are underutilized. Importantly, different factors were associated with the use of SM, highlighting distinct biopsychosocial mechanisms contributing to SM use in NHBs and NHWs.
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Amen TB, Varady NH, Rajaee S, Chen AF. 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. J Bone Joint Surg Am 2020; 102:811-820. [PMID: 32379122 DOI: 10.2106/jbjs.19.01194] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Cavanaugh AM, Rauh MJ, Thompson CA, Alcaraz J, Mihalko WM, Bird CE, Corbie-Smith G, Rosal MC, Li W, Shadyab AH, Gilmer T, LaCroix AZ. Racial/Ethnic Disparities in Physical Function Before and After Total Knee Arthroplasty Among Women in the United States. JAMA Netw Open 2020; 3:e204937. [PMID: 32412635 PMCID: PMC7229524 DOI: 10.1001/jamanetworkopen.2020.4937] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated. OBJECTIVE To examine trajectories of PF by race/ethnicity before and after TKA among older women. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among the prospective Women's Health Initiative with linked Medicare claims data. A total of 10 325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017. EXPOSURES Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively). MAIN OUTCOMES AND MEASURES Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time. RESULTS In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, -5.8 [95% CI, -8.0 to -3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, -7.8 [95% CI, -10.8 to -4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, -3.0 [95% CI, -5.3 to -0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods. CONCLUSIONS AND RELEVANCE This study suggests that black women had significantly poorer PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises.
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Affiliation(s)
- Alyson M. Cavanaugh
- Joint Doctoral Program in Public Health, San Diego State University/University of California, San Diego, San Diego
| | - Mitchell J. Rauh
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California
- Graduate School of Public Health, San Diego State University, San Diego, California
| | - Caroline A. Thompson
- Graduate School of Public Health, San Diego State University, San Diego, California
| | - John Alcaraz
- Graduate School of Public Health, San Diego State University, San Diego, California
| | - William M. Mihalko
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis
| | - Chloe E. Bird
- Health Care Division, RAND, Santa Monica, California
| | - Giselle Corbie-Smith
- Center for Health Equity Research, University of North Carolina School of Medicine, Chapel Hill
| | - Milagros C. Rosal
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, Worchester
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Aladdin H. Shadyab
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - Todd Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - Andrea Z. LaCroix
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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Hicks CW, Daya NR, Black JH, Matsushita K, Selvin E. Race and sex-based disparities associated with carotid endarterectomy in the Atherosclerosis Risk in Communities (ARIC) study. Atherosclerosis 2020; 292:10-16. [PMID: 31731080 PMCID: PMC6928429 DOI: 10.1016/j.atherosclerosis.2019.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/12/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS The indications for carotid endarterectomy (CEA) are well established. The aim of the current study was to investigate sex and race-based disparities in the incidence of CEA after adjusting for carotid artery stenosis risk factors. METHODS We conducted a prospective cohort analysis of 14,492 black and white participants in the Atherosclerosis Risk in Communities (ARIC) study without prevalent stroke at baseline (1987-1989). We used Kaplan-Meier curves and Cox proportional hazards models adjusting for sociodemographic, cardiovascular, and disease severity risk factors to quantify the associations of sex and race with incident CEA. RESULTS CEA was performed in 330 of 14,492 ARIC participants during a median of 27 years of follow-up [incidence rate 1.00 (95% CI 0.90-1.12) per 1000 persons-years]. The crude incidence of CEA varied significantly by sex [female vs. male: HR 0.60 (95% CI 0.48-0.74)] and race [black vs. white: HR 0.65 (95% CI 0.49-0.86)]. Adjustment for sociodemographic and cardiovascular risk factors, carotid intima-media thickness, and symptomatic status attenuated the association of sex with CEA [females vs. males HR 0.96 (0.76-1.22)], but black participants had a lower risk of incident CEA after adjustment [HR 0.68 (95% CI 0.49-0.95)]. CONCLUSIONS We found significant variation in the incidence of CEA procedures based on race that was independent of traditional risk factors and carotid IMT. Whether this disparity is a reflection of differences in disease presentation or access to care deserves investigation.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Natalie R Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Zelle BA, Morton-Gonzaba NA, Adcock CF, Lacci JV, Dang KH, Seifi A. Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures. J Orthop Surg Res 2019; 14:359. [PMID: 31718674 PMCID: PMC6852936 DOI: 10.1186/s13018-019-1402-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Socio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA. Methods The National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment. Results A total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p < 0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p < 0.05). Conclusions Besides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA.
| | - Nicolas A Morton-Gonzaba
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Christopher F Adcock
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - John V Lacci
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Khang H Dang
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Ali Seifi
- Department of Neurosurgery-Neuro Critical Care, UT Health San Antonio, San Antonio, TX, USA
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Eichinger JK, Greenhouse AR, Rao MV, Gordon ER, Brinton D, Li X, Curry EJ, Friedman RJ. Racial and sex disparities in utilization rates for shoulder arthroplasty in the United States disparities in shoulder arthroplasty. J Orthop 2019; 16:195-200. [PMID: 30906122 PMCID: PMC6411623 DOI: 10.1016/j.jor.2019.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To investigate racial disparities in shoulder arthroplasty (SA), accounting for demographic factors such as sex and age. METHODS Data for SAs (2011-2014) was queried from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Population-adjusted SA utilization rates, racial and sex differences by age, length of stay, insurer, and comorbidities were calculated. RESULTS Caucasians aged 45-64 are 54% more likely than African-Americans and 74% than Hispanics to receive surgery. For patients aged 65-84, the disparity is wider for African-Americans and narrower for Hispanics. CONCLUSIONS Policymakers and physicians should focus on further national efforts to alleviate healthcare disparities.
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Meints SM, Cortes A, Morais CA, Edwards RR. Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Manag 2019; 9:317-334. [PMID: 31140916 PMCID: PMC6587104 DOI: 10.2217/pmt-2018-0030] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022] Open
Abstract
The burden of pain is unequal across racial and ethnic groups. In addition to racial and ethnic differences in the experience of pain, there are racial and ethnic disparities in the assessment and treatment of pain. In this article, we provide a nonexhaustive review of the biopsychosocial mechanistic factors contributing to racial and ethnic differences in both the experience and treatment of pain. Using a modified version of the Socioecological Model, we focus on patient-, provider- and system-level factors including coping, perceived bias and discrimination, patient preferences, expectations, patient/provider communication, treatment outcomes and healthcare access. In conclusion, we provide psychosocial factors influencing racial and ethnic differences in pain and highlight future research targets and possible solutions to reduce these disparities.
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Affiliation(s)
- Samantha M Meints
- Department of Anesthesiology, Pain Management Center, Brigham & Women’s Hospital, Harvard Medical School, Chestnut Hill, MA 02467, USA
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alejandro Cortes
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Calia A Morais
- Department of Psychology, The University of Alabama, Tuscaloosa, AL 35487, USA
| | - Robert R Edwards
- Department of Anesthesiology, Pain Management Center, Brigham & Women’s Hospital, Harvard Medical School, Chestnut Hill, MA 02467, USA
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Demiralp B, Koenig L, Nguyen JT, Soltoff SA. Determinants of Hip and Knee Replacement: The Role of Social Support and Family Dynamics. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958019837438. [PMID: 30947603 PMCID: PMC6452775 DOI: 10.1177/0046958019837438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The objective of this study was to examine variations in the determinants of joint replacement (JR) across gender and age, with emphasis on the role of social support and family dynamics. We analyzed data from the US Health and Retirement Study (1998-2010) on individuals aged 45 or older with no prior receipt of JR. We used logistic regression to analyze the probability of receiving knee or hip replacement by gender and age (<65, 65+). We estimated the effect of demographic, health needs, economic, and familial support variables on the rate of JR. We found that being married/partnered with a healthy spouse/partner is positively associated with JR utilization in both age groups (65+ group OR: 1.327 and <65 group OR: 1.476). While this finding holds for men, it is not statistically significant for women. Among women younger than 65, having children younger than 18 lowers the odds (OR: 0.201) and caring for grandchildren increases the odds (1.364) of having a JR. Finally, elderly women who report availability of household assistance from a child have higher odds of receiving a JR as compared with elderly women without a child who could assist (OR: 1.297). No effect of available support from children was observed for those below 65 years old and elderly men. Our results show that intrafamily dynamics and familial support are important determinants of JR; however, their effects vary by gender and age. Establishing appropriate support mechanisms could increase access to cost-effective JR among patients in need of surgery.
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Affiliation(s)
| | - Lane Koenig
- 1 KNG Health Consulting, LLC, Rockville, MD, USA
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