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Imbroane MR, Badrinathan A, Friedl SL, Mo A, Tran A, Carrane H, Tseng ES, Ho VP. A critical view: Examining disparities regarding timely cholecystectomy. Surgery 2024; 176:1345-1351. [PMID: 39218740 DOI: 10.1016/j.surg.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/14/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Implicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy. METHODS We performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit. RESULTS Of 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit. CONCLUSION More than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.
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Affiliation(s)
| | | | - Sophia L Friedl
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Allison Mo
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Andrew Tran
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Hope Carrane
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Esther S Tseng
- Department of Surgery, The MetroHealth System, Cleveland, OH. https://twitter.com/esthertsengmd
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System, Cleveland, OH; Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
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Okewunmi J, Stern BZ, Arroyave Villada JS, Restrepo Mejia M, Zubizarreta N, Poeran J, Forsh DA. Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study. Orthopedics 2024; 47:e233-e240. [PMID: 38864645 DOI: 10.3928/01477447-20240605-03] [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: 06/13/2024]
Abstract
BACKGROUND Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States. MATERIALS AND METHODS The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported. RESULTS A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery. CONCLUSION These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 2024;47(5):e233-e240.].
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Morcos M, Duggan J, Young J, Lipa SA. Artificial Intelligence Portrayals in Orthopaedic Surgery: An Analysis of Gender and Racial Diversity Using Text-to-Image Generators. J Bone Joint Surg Am 2024:00004623-990000000-01155. [PMID: 39024391 DOI: 10.2106/jbjs.24.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND The increasing accessibility of artificial intelligence (AI) text-to-image generators offers a novel avenue for exploring societal perceptions. The present study assessed AI-generated images to examine the representation of gender and racial diversity among orthopaedic surgeons. METHODS Five prominent text-to-image generators (DALL·E 2, Runway, Midjourney, ImagineAI, and JasperArt) were utilized to create images for the search queries "Orthopedic Surgeon," "Orthopedic Surgeon's Face," and "Portrait of an Orthopedic Surgeon." Each query produced 80 images, resulting in a total of 240 images per generator. Two independent reviewers categorized race, sex, and age in each image, with a third reviewer resolving discrepancies. Images with incomplete or multiple faces were excluded. The demographic proportions (sex, race, and age) of the AI-generated images were then compared with those of the 2018 American Academy of Orthopaedic Surgeons (AAOS) census. RESULTS In our examination across all AI platforms, 82.8% of the images depicted surgeons as White, 12.3% as Asian, 4.1% as Black, and 0.75% as other; 94.5% of images were men; and a majority (64.4%) appeared ≥50 years old. DALL·E 2 exhibited significantly increased diversity in representation of both women and non-White surgeons compared with the AAOS census, whereas Midjourney, Runway, and ImagineAI exhibited significantly decreased representation. CONCLUSIONS The present study highlighted distortions in AI portrayal of orthopaedic surgeon diversity, influencing public perceptions and potentially reinforcing disparities. DALL·E 2 and JasperArt show encouraging diversity, but limitations persist in other generators. Future research should explore strategies for improving AI to promote a more inclusive and accurate representation of the evolving demographics of orthopaedic surgery, mitigating biases related to race and gender. CLINICAL RELEVANCE This study is clinically relevant as it investigates the accuracy of AI-generated images in depicting diversity among orthopaedic surgeons. The findings reveal significant discrepancies in representation by race and gender, which could impact societal perceptions and exacerbate existing disparities in health care.
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Affiliation(s)
- Mary Morcos
- Harvard Medical School, Boston, Massachusetts
| | | | - Jason Young
- Harvard Medical School, Boston, Massachusetts
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Shaina A Lipa
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
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Rudisill SS, Hornung AL, Akosman I, Amen TB, Lovecchio FC, Nwachukwu BU. Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting? J Shoulder Elbow Surg 2024; 33:1536-1546. [PMID: 38182016 DOI: 10.1016/j.jse.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.
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Affiliation(s)
| | - Alexander L Hornung
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Francis C Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Corso KA, Joo P, Ruppenkamp J, Holy CE, Coplan PM, Mesfin A. Racial and Health Insurance Differences in Patient Outcomes After Surgical Treatment for Cauda Equina Syndrome: A United States Retrospective Hospital Claims Database Analysis. Spine (Phila Pa 1976) 2023; 48:1373-1387. [PMID: 37235562 PMCID: PMC10484189 DOI: 10.1097/brs.0000000000004727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/22/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN Retrospective database evaluation. OBJECTIVES To study the association between race, health care insurance, mortality, postoperative visits, and reoperation within a hospital setting in patients with cauda equina syndrome (CES) undergoing surgical intervention. SUMMARY OF BACKGROUND DATA CES can lead to permanent neurological deficits if the diagnosis is missed or delayed. Evidence of racial or insurance disparities in CES is sparse. MATERIALS AND METHODS Patients with CES undergoing surgery from 2000 to 2021 were identified from the Premier Health care Database. Six-month postoperative visits and 12-month reoperations within the hospital were compared by race ( i.e ., White, Black, or Other [Asian, Hispanic, or other]) and insurance ( i.e. , Commercial, Medicaid, Medicare, or Other) using Cox proportional hazard regressions; covariates were used in the regression models to control for confounding. Likelihood ratio tests were used to compare model fit. RESULTS Among 25,024 patients, most were White (76.3%), followed by Other race (15.4% [ 8.8% Asian, 7.3% Hispanic, and 83.9% other]) and Black (8.3%). Models with race and insurance combined provided the best fit for estimating the risk of visits to any setting of care and reoperations. White Medicaid patients had the strongest association with a higher risk of 6-month visits to any setting of care versus White patients with commercial insurance (HR: 1.36 (1.26,1.47)). Being Black with Medicare had a strong association with a higher risk of 12-month reoperations versus White commercial patients (HR: 1.43 (1.10,1.85)). Having Medicaid versus Commercial insurance was strongly associated with a higher risk of complication-related (HR: 1.36 (1.21, 1.52)) and ER visits (HR: 2.26 (2.02,2.51)). Medicaid had a significantly higher risk of mortality compared with Commercial patients (HR: 3.19 (1.41,7.20)). CONCLUSIONS Visits to any setting of care, complication-related, ER visits, reoperation, or mortality within the hospital setting after CES surgical treatment varied by race and insurance. Insurance type had a stronger association with the outcomes than race. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Katherine A. Corso
- Medical Devices Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Peter Joo
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jill Ruppenkamp
- Medical Devices Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Chantal E. Holy
- Medical Devices Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Paul M. Coplan
- Medical Devices Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Addisu Mesfin
- University of Rochester School of Medicine and Dentistry, Rochester, NY
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Tornberg H, Kleinbart EP, Martin K, Hunter K, Gentile PM, Rivera-Pintado C, Kleiner MT, Miller LS, Fedorka CJ. Disparities in arthroplasty utilization for rotator cuff tear arthropathy. J Shoulder Elbow Surg 2023; 32:1981-1987. [PMID: 37230288 DOI: 10.1016/j.jse.2023.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA. METHODS A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races. RESULTS Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01). CONCLUSION Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.
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Affiliation(s)
- Haley Tornberg
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Emily P Kleinbart
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Kelsey Martin
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Research Institute, Cooper University Health Care, Camden, NJ, USA
| | - Pietro M Gentile
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | | | - Matthew T Kleiner
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Lawrence S Miller
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J Fedorka
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA.
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Martinez VH, Quirarte JA, Treffalls RN, McCormick S, Martin CW, Brady CI. In-Hospital Mortality Risk and Discharge Disposition Following Hip Fractures: An Analysis of the Texas Trauma Registry. Geriatr Orthop Surg Rehabil 2023; 14:21514593231200797. [PMID: 37701926 PMCID: PMC10493052 DOI: 10.1177/21514593231200797] [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: 06/19/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Background In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations. Objective Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures. Methods A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions. Results There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method. Conclusion Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.
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Affiliation(s)
- Victor H. Martinez
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
| | - Jaime A. Quirarte
- University of Texas Health Science Center at Houston Department of Orthopedic Surgery, Houston, TX, USA
| | - Rebecca N. Treffalls
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
| | - Sekinat McCormick
- UT Health San Antonio Department of Orthopaedics, San Antonio, TX, USA
| | - Case W. Martin
- UT Health San Antonio Department of Orthopaedics, San Antonio, TX, USA
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Boakye LAT, Parker EB, Chiodo CP, Bluman EM, Martin EA, Smith JT. The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions. J Bone Joint Surg Am 2023; 105:1062-1071. [PMID: 36996237 DOI: 10.2106/jbjs.22.01149] [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: 04/01/2023]
Abstract
BACKGROUND Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores. METHODS We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors. RESULTS For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores. CONCLUSIONS Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lorraine A T Boakye
- Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Emily B Parker
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Chiodo
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric M Bluman
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Martin
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy T Smith
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Amen TB, Liimakka AP, Jain B, Rudisill SS, Bedair HS, Chen AF. Total Joint Arthroplasty Utilization After Orthopaedic Surgery Referral: Identifying Disparities Along the Care Pathway. J Arthroplasty 2023; 38:424-430. [PMID: 36150431 DOI: 10.1016/j.arth.2022.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although racial and ethnic disparities in total joint arthroplasty (TJA) have been thoroughly described, only a few studies have sought to determine exactly where along the care pathway these disparities are perpetuated. The purpose of this study was to investigate disparities in TJA utilization occurring after patients who had diagnosed hip or knee osteoarthritis were referred to a group of orthopaedic providers within an integrated academic institution. METHODS A retrospective, multi-institutional study evaluating patients with diagnosed hip or knee osteoarthritis was conducted between 2015 and 2019. Information pertaining to patient demographics, timing of clinic visits, and subsequent surgical intervention was collected. Utilization rates and time to surgery from the initial clinic visit were calculated by race, and logistic regressions were performed to control for various demographic as well as health related variables. RESULTS White patients diagnosed with knee osteoarthritis were significantly more likely to receive total knee arthroplasty (TKA) than Black and Hispanic patients, even after adjusting for various demographic variables (Black patients: odds ratio [OR] = 0.63, 95% CI = 0.55-0.72, P = .002; Hispanic patients: OR = 0.69, 95% CI = 0.57-0.83, P = .039). Similar disparities were found among patients diagnosed with hip osteoarthritis who underwent total hip arthroplasty (THA; Black patients: OR = 0.73, 95% CI = 0.60-0.89, P = <.001; Hispanic patients: OR = 0.72, 95% CI = 0.53-0.98, P <.001). There were no differences in time to surgery between races (P > .05 for all). CONCLUSION In this study, racial and ethnic disparities in TJA utilization were found to exist even after referral to an orthopaedic surgeon, highlighting a critical point along the care pathway during which inequalities in TJA care can emerge. Similar time to surgery between White, Black, and Hispanic patients suggest that these disparities in TJA utilization may largely be perpetuated before surgical planning while patients are deciding whether to undergo surgery. Further studies are needed to better elucidate which patient and provider-specific factors may be preventing these patients from pursuing surgery during this part of the care pathway. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Adriana P Liimakka
- Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bhav Jain
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Samuel S Rudisill
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
Mentorship and sponsorship are part of academia because they are vital for professional and personal development. Inclusive mentorship is defined as mentoring across differences. It highlights the need of all mentors to be well-versed culturally and to recognize and circumvent bias and microaggressions. Inclusive mentorship can also elevate underrepresented populations in medicine and create intercultural relationships that also benefit the relationships we have with our diversifying patient populations. There are still several barriers prohibiting inclusive mentorship from being widely understood and employed. This article discusses the importance of and techniques for improving inclusive mentorship.
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Affiliation(s)
| | - Erica Taylor
- Duke University School of Medicine, PO Box 1726, Wake Forest, NC 27587, USA.
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Montgomery BK, Joseph G, Segovia N, Koltsov J, Thomas TL, Vorhies JS, Tileston KR. The Influence of Race, Income, and Sex on Treatment and Complications of Common Pediatric Orthopedic Fractures. Orthopedics 2023; 46:e156-e160. [PMID: 36623278 DOI: 10.3928/01477447-20230104-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite best intentions, health care disparities exist and can consequently impact patient care. Few studies have examined the impact of disparities in pediatric orthopedic populations. The current study aimed to determine if the treatment type or complication rates of supracondylar, both-bone forearm, or femur fractures are associated with race, ethnicity, sex, or socioeconomic status. The New York Healthcare Cost and Utilization Project's database was used to identify all pediatric patients treated for supracondylar humerus fractures, both-bone forearm fractures, and femoral shaft fractures in 2016. Risk-adjusted relationships with race, ethnicity, sex, hospital location, and median income by zip code were assessed with multivariable logistic regression. Patients who were non-White, resided in the zip codes with the lowest median income (<$42,999 annually), and were treated in metropolitan areas were more likely to receive nonoperative treatments for supracondylar humerus fractures. Female patients with a femoral shaft fracture were less likely to be treated with open reduction and internal fixation vs intramedullary fixation. Finally, complications were not associated with patient race, sex, or socioeconomic statuses. These findings bring attention to health care disparities in the treatment of common pediatric orthopedic fractures. Further studies investigating the underlying etiology behind these disparities are warranted. [Orthopedics. 20XX;XX(X):xx-xx].
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Rakutt MJ, Bracey DN, Cohen-Rosenblum A, Sculco PK, Sabatini FM, Jacobs CA, Duncan ST, Landy DC. Hemoglobinopathy is Associated With Total Hip Arthroplasty Indication Even Beyond Sickle Cell Anemia. Arthroplast Today 2022; 19:101062. [PMID: 36845292 PMCID: PMC9947981 DOI: 10.1016/j.artd.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background The extent to which hemoglobinopathies other than sickle anemia (HbSS) are associated with hip osteonecrosis is unknown. Sickle cell trait (HbS), hemoglobin SC (HbSC), and sickle/β-thalassemia (HbSβTh) may also predispose to osteonecrosis of the femoral head (ONFH). We sought to compare the distributions of indications for a total hip arthroplasty (THA) in patients with and without specific hemoglobinopathies. Methods PearlDiver, an administrative claims database, was used to identify 384,401 patients aged 18 years or older undergoing a THA not for fracture from 2010 to 2020, with patients grouped by diagnosis code (HbSS N = 210, HbSC N = 196, HbSβTh N = 129, HbS N = 356). β-Thalassemia minor (N = 142) acted as a negative control, and patients without hemoglobinopathy as a comparison group (N = 383,368). The proportion of patients with ONFH was compared to patients without it by hemoglobinopathy groups using chi-squared tests before and after matching on age, sex, Elixhauser Comorbidity Index, and tobacco use. Results The proportion of patients with ONFH as the indication for THA was higher among those with HbSS (59%, P < .001), HbSC (80%, P < .001), HbSβTh (77%, P < .001), and HbS (19%, P < .001) but not with β-thalassemia minor (9%, P = .6) than the proportion of patients without hemoglobinopathy (8%). After matching, the proportion of patients with ONFH remained higher among those with HbSS (59% vs 21%, P < .001), HbSC (80% vs 34%, P < .001), HbSβTh (77% vs 26%, P < .001), and HbS (19% vs 12%, P < .001). Conclusions Hemoglobinopathies beyond sickle cell anemia were strongly associated with having osteonecrosis as the indication for THA. Further research is needed to confirm whether this modifies THA outcomes.
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Affiliation(s)
- Maxwell J. Rakutt
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | - Daniel N. Bracey
- Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Anna Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University, New Orleans, LA, USA
| | - Peter K. Sculco
- Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Franco M. Sabatini
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | - Cale A. Jacobs
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | - Stephen T. Duncan
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | - David C. Landy
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA,Corresponding author. Department of Orthopaedic Surgery, University of Kentucky, 740 S. Limestone, Suite K-419, Lexington, KY 40513, USA. Tel.: +1 713 305 4266.
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Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty. J Arthroplasty 2022; 37:2116-2121. [PMID: 35537609 DOI: 10.1016/j.arth.2022.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/10/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities within the field of total joint arthroplasty (TJA) have been extensively reported. To date, however, it remains unknown how these disparities have translated to the outpatient TJA (OP-TJA) setting. The purposes of this study were to compare relative OP-TJA utilization rates between White and Black patients from 2011-2019 and assess how these differences in utilization have evolved over time. METHODS We conducted a retrospective review from 2011-2019 using the National Surgical Quality Improvement Program (NSQIP). Differences in the relative utilization of OP (same-day discharge) versus inpatient TJA between White and Black patients were assessed and trended over time. Multivariable logistic regressions were run to adjust for baseline patient factors and comorbidities. RESULTS During the study period, Black patients were significantly less likely to undergo OP-TJA when compared to White patients (P < .001 for both outpatient total knee arthroplasty and outpatient total hip arthroplasty [OP-THA]). From 2011 to 2019, an emerging disparity was found in outpatient total knee arthroplasty and OP-THA utilization between White and Black patients (eg, White versus Black OP-THA: 0.4% versus 0.6% in 2011 compared with 10.2% versus 5.9% in 2019, Ptrend < .001). These results held in all adjusted analyses. CONCLUSION In this study we found evidence of emerging and worsening racial disparities in the relative utilization of OP-TJA procedures between White and Black patients. These results highlight the need for early intervention by orthopaedic surgeons and policy makers alike to address these emerging inequalities in access to care before they become entrenched within our systems of orthopaedic care.
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Suleiman LI, Tucker K, Ihekweazu U, Huddleston JI, Cohen-Rosenblum AR. Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration. J Arthroplasty 2022; 37:1421-1425. [PMID: 35158005 DOI: 10.1016/j.arth.2022.02.017] [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: 12/03/2021] [Revised: 01/16/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.
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Affiliation(s)
- Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL
| | | | | | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Anna R Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
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15
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LGBTQ+ in Orthopaedics: Creating an Open and Inclusive Environment. J Am Acad Orthop Surg 2022; 30:599-606. [PMID: 35609262 DOI: 10.5435/jaaos-d-20-01268] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals may encounter added challenges in the healthcare setting. Both providers and patients may face discrimination based on their sexual orientation or gender identity, which may lead to avoidance or delay in seeking care. LGBTQ+ physicians often choose not to disclose their sexual orientation because of concerns about harassment, isolation, and depression. Orthopaedic surgery remains the least diverse medical specialty and there is inconsistent training about the needs and cultural issues that affect sexual and gender minority individuals. Furthermore, orthopaedic research specific to LGBTQ+ patients and physicians is exceedingly limited. By encouraging mentorship and improving awareness of the challenges that this community faces, the field of orthopaedic surgery can work to foster an open and inclusive environment that is conducive to the experience of all patients, trainees, and healthcare personnel.
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Feroe AG, Hutchinson LE, Miller PE, Samora JB, Kocher MS. Knowledge, Attitudes, and Practices in the Orthopaedic Care of Sexual and Gender Minority Youth: A Survey of Two Pediatric Academic Hospitals. Clin Orthop Relat Res 2022; 480:1313-1328. [PMID: 35167510 PMCID: PMC9191605 DOI: 10.1097/corr.0000000000002143] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lesbian, gay, bisexual, transgender, and queer (LGBTQ) children and adolescents continue to experience unmet healthcare needs, partly because of clinician biases, discrimination, and inadequate education. Although clinician attitudes and knowledge related to sexual and gender minority health have been well studied in other medical specialties, these have been scarcely studied in orthopaedics. QUESTIONS/PURPOSES (1) What are pediatric orthopaedic healthcare professionals' attitudes (perceived importance, openness, comfort, and confidence) toward caring for sexual and gender minority youth? (2) What do pediatric orthopaedic healthcare professionals know about caring for this patient population? (3) What factors are associated with clinician attitude and/or knowledge? (4) What existing initiatives to improve orthopaedic care for this population are clinicians aware of at their home institutions? METHODS All 123 orthopaedic healthcare professionals at two pediatric academic hospitals in the Midwestern and Northeastern United States were sent a 34-question, internet-based, anonymous survey. The survey queried respondent demographics, attitudes, knowledge, and practice behaviors at their home institutions related to the care of sexual and gender minority youth. Respondent attitudes were queried using the Attitudes Summary Measure, which is a survey instrument that was previously validated to assess clinicians' attitudes regarding sexual and gender minority patients. Items used to assess knowledge and practice behaviors were developed by content experts in LGBTQ health and/or survey design, as well as orthopaedic surgeons to improve face validity and to mitigate push-polling. Attitude and knowledge items used a 5-point Likert scale. Sixty-six percent (81 of 123) of clinicians completed the survey. Of those, 47% (38 of 81) were physicians, 73% (59 of 81) were licensed for fewer than 20 years, 63% (51 of 81) were women, and 53% (43 of 81) described themselves as liberal-leaning. The response proportions were 73% (38 of 52) among eligible physicians specifically and 61% (43 of 71) among other clinicians (nurse practitioners, physician assistants, and registered nurses). To assess potential nonresponse bias, we compared early responders (within 2 weeks) with late responders (after 2 weeks) and found no differences in responder demographics or in questionnaire responses (all p > 0.05). The main outcome measures included responses to the attitude and knowledge questionnaire, as well as the existing practices questionnaire. To answer our research questions regarding clinician attitudes knowledge and awareness of institutional initiatives, we compared participant responses using chi-square tests, the Student t-test, and the McNemar tests, as appropriate. To answer our research question on factors associated with questionnaire responses, we reported data for each question, stratified by hospital, years since licensure, and political leaning. Comparisons were conducted across strata using chi-square tests for Likert response items and ANOVA for continuous response items. All p values less than 0.05 were considered significant. RESULTS Of the respondents who reported feeling comfortable treating lesbian, gay, and bisexual (sexual minority) youth, a small proportion reported feeling confident in their knowledge about these patients' health needs (99% [80 of 81] versus 63% [51 of 80], 36% reduction [95% confidence interval 23% to 47%]; p < 0.001). Similarly, of those who reported feeling comfortable treating transgender (gender minority) youth, a smaller proportion reported feeling confident in their knowledge of their health needs (94% [76 of 81] versus 49% [37 of 76], 45% reduction [95% CI 31% to 59%]; p < 0.001). There was substantial interest in receiving more education regarding the health concerns of LGBTQ people (81% [66 of 81]) and being listed as an LGBTQ-friendly clinician (90% [73 of 81]). Factors that were associated with select attitude and knowledge items were duration of licensure and political leaning; gender identity, institutional affiliation, educational degree, or having LGBTQ friends and family were not associated. Many respondents were aware of the use of clinic intake forms and the electronic medical record to collect and provide patient gender identity and sexual orientation data at their practice, as well as signage and symbols (for example, rainbow posters) to cultivate LGBTQ-welcoming clinic spaces. CONCLUSION There were varying degrees of confidence and knowledge regarding the health needs of sexual and gender minority youth among pediatric orthopaedic healthcare professionals. There was considerable interest in more focused training and better use of medical technologies to improve care for this population. CLINICAL RELEVANCE The study findings support the further investment in clinician training opportunities by healthcare administrators and orthopaedic associations related to the care of sexual and gender minority patients, as well as in the expansion of medical documentation to record and report important patient information such as pronouns and gender identity. Simultaneously, based on these findings, clinicians should engage with the increasing number of educational opportunities, explore their personal biases, and implement changes into their own practices, with the ultimate goal of providing equitable and informed orthopaedic care.
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Affiliation(s)
- Aliya G. Feroe
- Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Lauren E. Hutchinson
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Patricia E. Miller
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Julie Balch Samora
- Department of Orthopaedic Surgery, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Mininder S. Kocher
- Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
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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: 28] [Impact Index Per Article: 14.0] [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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Abstract
Osteoporosis is a skeletal disease characterized by low bone density and poor bone quality that weakens bones and increases the risk of fractures. Serious consequences of fractures include disability, loss of independence, and death. Despite the availability of clinical tools to evaluate fracture risk and medications to reduce fracture risk, many or most patients at risk, even those with a recent fracture, are not being treated. This represents a large osteoporosis treatment gap that has reached a crisis level. Importantly, the treatment gap is not evenly distributed among populations of different race/ethnicity. Black women are less likely to have bone density testing when indicated, are less likely to be treated, and have worse outcomes after a fracture than White women. This is a review and update of race-based disparities and inequalities, with suggestions for interventions to optimize patient care.
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Affiliation(s)
- E Michael Lewiecki
- E. Michael Lewiecki, MD, New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM
- Sarah F. Erb, FNP-C, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Sarah F Erb
- E. Michael Lewiecki, MD, New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM
- Sarah F. Erb, FNP-C, University of New Mexico Health Sciences Center, Albuquerque, NM
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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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Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Members. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202202000-00005. [PMID: 35134006 PMCID: PMC8816373 DOI: 10.5435/jaaosglobal-d-21-00028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to perform a cross-sectional analysis on the gender composition of practicing academic orthopaedic surgeons using three databases composed of clinical orthopaedic surgeons.
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21
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Racial and Ethnic Disparities in Hip Fracture Surgery Care in the United States From 2006 to 2015: A Nationwide Trends Study. J Am Acad Orthop Surg 2022; 30:e182-e190. [PMID: 34520407 DOI: 10.5435/jaaos-d-21-00137] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/12/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in the surgical treatment of hip fractures have been previously reported, demonstrating delayed time to surgery and worse perioperative outcomes for minority patients. However, data are lacking on how these disparities have trended over time and whether national efforts have succeeded in reducing them. The aim of this study was to investigate temporal trends in racial and ethnic disparities in perioperative metrics for patients undergoing hip fracture surgery in the United States from 2006 to 2015. METHODS The National Inpatient Sample was queried for White, Black, Hispanic, and Asian patients who underwent hip fracture surgery between 2006 and 2015. Perioperative metrics, including delayed time to surgery (≥2 calendar days from admission to surgical intervention), length of stay (LOS), total inpatient complications, and mortality, were trended over time. Changes in racial and ethnic disparities were assessed using linear and logistic regression models. RESULTS During the study period, there were persistent disparities in delayed time to surgery for White versus Black, Hispanic, and Asian patients (eg, White versus Black: 30.1% versus 39.7% in 2006 and 22% versus 28.8% in 2015, Ptrend> 0.05 for all). Although disparities in total LOS remained consistent for White versus Black patients (Ptrend= 0.97), these disparities improved for White versus Hispanic and Asian patients (eg, White versus Hispanic: 4.8 days versus 5.3 in 2006 and 4.1 days versus 4.4 in 2015, Ptrend < 0.05 for both). DISCUSSION Racial and ethnic disparities were persistent in time to surgery and discharge disposition for hip fracture surgery between White and minority patients from 2006 to 2015 in the United States. These disparities particularly affected Black patients. Although there were encouraging signs of improving disparities in the LOS, these findings highlight the need for renewed orthopaedic initiatives and healthcare reform policies aimed at reducing perioperative disparities in orthopaedic trauma care.
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22
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Farley KX, Dawes AM, Wilson JM, Toston RJ, Hurt JT, Gottschalk MB, Navarro RA, Wagner ER. Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States. JB JS Open Access 2022; 7:JBJSOA-D-21-00144. [PMID: 35673617 PMCID: PMC9165742 DOI: 10.2106/jbjs.oa.21.00144] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities.
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Affiliation(s)
- Kevin X. Farley
- Department of Orthopaedic Surgery, Oakland University William Beaumont Orthopaedics, Royal Oaks, Michigan
| | - Alexander M. Dawes
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Jacob M. Wilson
- Division of Adult Reconstruction, Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Roy J. Toston
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - John T. Hurt
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Michael B. Gottschalk
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente, Pasadena, California
| | - Eric R. Wagner
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
- Email for corresponding author:
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Hagan MJ, Pertsch NJ, Leary OP, Zheng B, Camara-Quintana JQ, Niu T, Mueller K, Boghani Z, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States. JOURNAL OF SPINE SURGERY 2021; 7:277-288. [PMID: 34734132 DOI: 10.21037/jss-21-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/30/2021] [Indexed: 11/06/2022]
Abstract
Background Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI). Methods We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression. Results We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression. Conclusions Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Joaquin Q Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Kyle Mueller
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Zain Boghani
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
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Michelson JD. CORR Insights®: Smoking, Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study. Clin Orthop Relat Res 2021; 479:814-816. [PMID: 33394607 PMCID: PMC8083929 DOI: 10.1097/corr.0000000000001633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 01/31/2023]
Affiliation(s)
- James D Michelson
- J. D. Michelson, Professor of Orthopaedic Surgery, Director of Clinical Informatics, University of Vermont, Larner College of Medicine Department of Orthopaedics and Rehabilitation, Burlington, VT, USA
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Ramsey DC, Lawson MM, Stuart A, Sodders E, Working ZM. Orthopaedic Care of the Transgender Patient. J Bone Joint Surg Am 2021; 103:274-281. [PMID: 33252585 DOI: 10.2106/jbjs.20.00628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
» A transgender person is defined as one whose gender identity is incongruent with their biological sex assigned at birth. This highly marginalized population numbers over 1.4 million individuals in the U.S.; this prevalence skews more heavily toward younger generations and is expected to increase considerably in the future. » Gender-affirming hormone therapy (GAHT) has physiologic effects on numerous aspects of the patient's health that are pertinent to the orthopaedic surgeon, including bone health, fracture risk, and perioperative risks such as venous thromboembolism and infection. » Language and accurate pronoun usage toward transgender patients can have a profound effect on a patient's experience and on both objective and subjective outcomes. » Gaps in research concerning orthopaedic care of the transgender patient are substantial. Specific areas for further study include the effects of GAHT on fracture risk and healing, outcome disparities and care access across multiple subspecialties, and establishment of perioperative management guidelines.
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Affiliation(s)
- Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Michelle M Lawson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Ariana Stuart
- Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Emelia Sodders
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Zachary M Working
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
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Value-based Healthcare: Health Literacy's Impact on Orthopaedic Care Delivery and Community Viability. Clin Orthop Relat Res 2020; 478:1984-1986. [PMID: 32639307 PMCID: PMC7431262 DOI: 10.1097/corr.0000000000001397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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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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Comer-HaGans D, Austin S, Ramamonjiarivelo Z, Matthews AK. Diabetes Standard of Care Among Individuals Who Have Diabetes With and Without Cognitive Limitation Disabilities. DIABETES EDUCATOR 2019; 46:94-107. [DOI: 10.1177/0145721719896262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study is to examine diabetes standard of care among individuals who have diabetes with and without cognitive limitation disabilities (CLDs). Individuals with CLDs are more likely to develop diabetes and less likely to participate in diabetes standard of care services compared to those without CLDs. Methods We used pooled cross-sectional data (2011-2016) from the Household Component of the Medical Expenditure Panel Survey (HC-MEPS). Dependent variables were utilization of dilated eye exams, foot checks, A1C blood tests, and engagement in moderate or vigorous physical exercise 5 times per week. Our independent variable was diabetes with CLDs vs diabetes without CLDs. We controlled for predisposing, enabling, and need factors. Results Findings suggest that individuals with diabetes and CLDs were less likely to engage in moderate or vigorous physical exercise 5 times per week compared to individuals without CLDs. For other diabetes care services, individuals with CLDs are as likely to participate in health services utilization as those without CLDs. Conclusions Our study supports research that indicates individuals with diabetes and CLDs were less likely to participate in physical exercise compared to individuals without CLDs. Conversely, individuals with diabetes and CLDs were just as likely to receive a dilated eye exam, have their feet checked, and have their A1C checked as individuals without CLDs, which is a very encouraging finding.
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Affiliation(s)
| | - Shamly Austin
- Gateway Health, Research & Development, Quality Improvement Department, Pittsburgh, Pennsylvania
| | - Zo Ramamonjiarivelo
- Texas State University, School of Health Administration, Encino Hall, San Marcos, Texas
| | - Alicia K. Matthews
- University of Illinois at Chicago, College of Nursing, Chicago, Illinois
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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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Furlan JC, Craven BC, Fehlings MG. Is there any gender or age-related discrepancy in the waiting time for each step in the surgical management of acute traumatic cervical spinal cord injury? J Spinal Cord Med 2019; 42:233-241. [PMID: 31573451 PMCID: PMC6781466 DOI: 10.1080/10790268.2019.1614291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Context/Objective: Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Design: Retrospective cohort study. Setting: Quaternary spine trauma center. Participants: This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Interventions: Spinal cord decompression. Outcome Measures: Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. Results: There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. Conclusion: The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada,Correspondence to: Julio C. Furlan, 520 Sutherland Drive, Room 206-J, Toronto, Ontario, Canada, M4G 3V9; Ph:416-597-4322 (Ext. 6129); 416-425-9923. E-mail:
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada,Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
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Omidele OO, Finkelstein M, Omorogbe A, Palese M. Radical Prostatectomy Sociodemographic Disparities Based on Hospital and Physician Volume. Clin Genitourin Cancer 2019; 17:e1011-e1019. [PMID: 31239239 DOI: 10.1016/j.clgc.2019.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/22/2019] [Accepted: 05/26/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The objective of this study was to assess the impact of volume status on socio-demographic disparities for radical prostatectomy (RP) in New York State. PATIENTS AND METHODS All patients undergoing RP from 2006 to 2014 with an admitting or principal diagnosis of prostate cancer were identified. All 40,533 cases were separated into volume groups stratified by hospital and physician quartiles with a goal of maintaining consistent numbers between the 4 volume groups. Patient-level data included race, ethnicity, Charlson Comorbidity Index (CCI), median income by zip code, and source of payment. Hospital-level data included hospital location, teaching status, health service area, and facility number. Continuous and categorical variables were compared between cohorts using the Mann-Whitney-Wilcoxon test and Pearson χ2 tests, respectively. Multivariate regression analysis was conducted to assess predictors of access to very high-volume facilities and physician groups as well as predictors of receiving a minimally invasive RP. RESULTS Of 40,533 total cases, 9602 (24%) were conducted at low-volume hospitals, 9208 (22%) were conducted at medium-volume hospitals, 8478 (21%) were conducted at high-volume hospitals, and 13,245 (33%) were conducted at very high-volume hospitals. Negative predictors of receiving care from a very high-volume physician include increased CCI, Asian race, black race, unknown race, Medicaid status, age 65 to 79 years, and age 80 to 130 years (P < .001). Negative predictors of receiving care from a very high-volume facility include Asian race, black race, unknown race, Medicaid status, and self-payment status (P < .001). CONCLUSION Socioeconomic disparities exist in New York State for RP and are associated with disadvantaged groups being overrepresented in low-volume hospital and physician groups.
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Affiliation(s)
- Olamide O Omidele
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Mark Finkelstein
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aisosa Omorogbe
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Palese
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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Leopold SS, Beadling L, Calabro AM, Dobbs MB, Gebhardt MC, Gioe TJ, Manner PA, Porcher R, Rimnac CM, Wongworawat MD. Editorial: The Complexity of Reporting Race and Ethnicity in Orthopaedic Research. Clin Orthop Relat Res 2018; 476:917-920. [PMID: 29533248 PMCID: PMC5916598 DOI: 10.1007/s11999.0000000000000259] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S Leopold
- S. S. Leopold, Editor-In-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA L. Beadling, Managing Director, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA A. M. Calabro, Associate Editor, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA M. B. Dobbs, M. C. Gebhardt, T. J. Gioe, P. A, Manner, R. Porcher, C. M. Rimnac, M. D. Wongworawat Senior Editor, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA
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Stein A. Race and ethnicity as predictors of hospital-acquired conditions after total hip arthroplasty and total knee arthroplasty. Int J Orthop Trauma Nurs 2017; 27:16-22. [PMID: 28673450 DOI: 10.1016/j.ijotn.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/22/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Anne Stein
- Northern Michigan University, 1401 Presque Isle Ave, Marquette, MI 49855, United States.
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Schairer WW, Nwachukwu BU, Warren RF, Dines DM, Gulotta LV. Operative Fixation for Clavicle Fractures-Socioeconomic Differences Persist Despite Overall Population Increases in Utilization. J Orthop Trauma 2017; 31:e167-e172. [PMID: 28538455 DOI: 10.1097/bot.0000000000000820] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Clavicle fractures were traditionally treated conservatively, but recent evidence has shown improved outcomes with surgical management. The purpose of this study was to evaluate the recent trends in operative treatment of clavicle fractures, and to analyze for patient related factors that may affect treatment strategy. METHODS The Healthcare Cost and Utilization Project (HCUP) California and Florida inpatient, outpatient, and the Emergency Department databases were used to identify all patients with clavicle fractures between 2005 and 2010. We evaluated the overall number of procedures over the study period and calculated the rates of operative and nonoperative treatment by tracking a large cohort of emergency department patients with clavicle fractures. Poisson and multivariable regression were used to identify trends and patient factors associated with treatment. RESULTS There was a 290% increase in the annual number clavicle fracture procedures over the study period. The rate of fixation increased from 3.7% to 11.1% (P < 0.001). Significant increases were seen in all patient age groups less than 65 years. Comparatively, higher rates of fixation were found in patients who were white, privately insured, and of high-income status. Lower income status was also associated with delayed surgery. CONCLUSIONS The rates of clavicle fracture fixation have increased. However, there are differences associated with socioeconomic factors including race, insurance type, and income level. In part, this likely representing both underutilization and overutilization but may also show differential access to care. This differential utilization suggests both that further work is needed to more clearly define indications for operative versus nonoperative management and to further evaluate referral systems and access to care to ensure equal and quality treatment is available for all patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William W Schairer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
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Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter? J Racial Ethn Health Disparities 2017; 5:287-292. [DOI: 10.1007/s40615-017-0369-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 03/29/2017] [Accepted: 04/03/2017] [Indexed: 01/21/2023]
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Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State. J Pediatr Orthop 2017; 36:459-64. [PMID: 25929779 DOI: 10.1097/bpo.0000000000000494] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. METHODS Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal). RESULTS Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal. CONCLUSIONS There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Lorraine Evans
- Office of Diversity and Inclusion; Georgia Regents University
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Badley EM, Canizares M, MacKay C, Mahomed NN, Davis AM. Surgery or consultation: a population-based cohort study of use of orthopaedic surgeon services. PLoS One 2013; 8:e65560. [PMID: 23750266 PMCID: PMC3672140 DOI: 10.1371/journal.pone.0065560] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 04/26/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon. METHODS Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1(st), 2004 and September 30(th), 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months. RESULTS Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0-24 and 25-44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0-24: OR 3.45 95%CI 3.33-3.57; age 25-44: OR 1.30 95%CI 1.27-1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions. CONCLUSION A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.
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Affiliation(s)
- Elizabeth M Badley
- The Arthritis Community Research and Evaluation Unit, Division of Health Care and Outcomes Research, Toronto Western Research Institute, Toronto, Ontario, Canada.
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Okike K, Utuk ME, White AA. Racial and ethnic diversity in orthopaedic surgery residency programs. J Bone Joint Surg Am 2011; 93:e107. [PMID: 21938358 DOI: 10.2106/jbjs.k.00108] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the U.S. population is increasingly diverse, the field of orthopaedic surgery has historically been less diverse. The purpose of this study was to quantify the representation of racial and ethnic minorities among orthopaedic surgery residents compared with those in other fields of medicine and to determine how these levels of diversity have changed over time. METHODS We determined the representation of minorities among residents in orthopaedic surgery and in other fields by analyzing the Graduate Medical Education reports published annually by the Journal of the American Medical Association (JAMA), which provided data for African-Americans from 1968 to 2008, Hispanics from 1990 to 2008, Asians from 1995 to 2008, and American Indians/Alaskan Natives and Native Hawaiians/Pacific Islanders from 2001 to 2008. RESULTS During the 1990s and 2000s, representation among orthopaedic residents increased rapidly for Asians (+4.53% per decade, p < 0.0001) and gradually for Hispanics (+1.37% per decade, p < 0.0001) and African-Americans (+0.68% per decade, p = 0.0003). Total minority representation in orthopaedics averaged 20.2% during the most recent years studied (2001 to 2008), including 11.7% for Asians, 4.0% for African-Americans, 3.8% for Hispanics, 0.4% for American Indians/Alaskan Natives, and 0.3% for Native Hawaiians/Pacific Islanders. However, orthopaedic surgery was significantly less diverse than all of the other residencies examined during this time period (p < 0.001). This was due primarily to the lower representation of Hispanics and Asians in orthopaedic surgery than in any of the other fields of medicine. CONCLUSIONS Minority representation in orthopaedic residency programs has increased over time for Asians, Hispanics, and African-Americans. In spite of these gains, orthopaedic surgery has remained the least diverse of the specialty training programs considered in this study. While further efforts are needed to determine the factors underlying this lack of representation, we suggest a series of interventions that can be expected to enhance diversity in orthopaedic residencies as well as in the profession as a whole.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Abstract
BACKGROUND For minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA. QUESTIONS/PURPOSES We therefore (1) defined utilization disparities for total joint arthroplasty in racial and ethnic minorities, (2) delineated patient and provider factors contributing to the lower total joint arthroplasty utilization, and (3) discussed potential interventions and future research that may increase total joint arthroplasty utilization by racial and ethnic minorities. METHODS We searched the MEDLINE database and identified 67 articles, 21 of which we excluded. By searching Google and Google Scholar and reference lists of the included articles, we identified 40 articles for this review. Utilization disparities were defined by documented lower utilization of THA or TKA in specific racial or ethnic groups. RESULTS Lower utilization of THA and TKA among some racial and ethnic minority groups (African Americans, Hispanics) is not explained by decreased disease prevalence or disability. At least some utilization disparities are independent of income, geographic location, education, and insurance status. Causal factors related to racial and ethnic disparities may be related in part to patient factors such as health literacy, trust, and preferences. Provider unconscious or conscious biases or beliefs also play a role in at least some healthcare disparities. CONCLUSIONS Racial and ethnic THA and TKA utilization disparities exist. These disparities are not explained by lower disease prevalence. The existing data suggest patient education, improved health literacy regarding THA and TKA, and a patient-provider relationship leading to improved trust would be beneficial. Research providing a better understanding of the root causes of these disparities is needed.
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Affiliation(s)
- Kaan Irgit
- Department of Orthopaedics, Geisinger Clinic, Geisinger Medical Center, 100 N Academy Road, Danville, PA 17822 USA
| | - Charles L. Nelson
- Department of Orthopaedics, Geisinger Clinic, Geisinger Medical Center, 100 N Academy Road, Danville, PA 17822 USA
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