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Nham FH, Kassis E, Xu W, El-Othmani MM, Sarpong NO. Race and ethnic disparities arthroplasty trends and hotspots: Bibliometric analysis. J Orthop 2024; 56:141-150. [PMID: 38872840 PMCID: PMC11167205 DOI: 10.1016/j.jor.2024.05.021] [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] [Received: 04/15/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Introduction Despite continual advancements in total joint arthroplasty and perioperative optimization, there remains national variability in outcomes. These outcome variabilities have been in part attributed to racial and ethnic disparities in healthcare quality and access to care. This study aims to identify arthroplasty racial and ethnic disparities research and to predict future hotspots. Methods Ethnic and racial disparities articles between 1992 and 2022 were queried from the Web of Science Core Collection of Clarivate Analytics. Bibliometric indicators in excel format were extracted and subsequently imported for further analysis. Bibliometrix and VOSviewer analyzed current and previous research. Results Database search yielded 234 total articles assessing racial and ethnic disparities between 1992 and 2022. Twenty-six countries published manuscripts with the United States producing the majority of publications. The Veterans Health Administration and University of Pittsburgh were the most relevant institutions. Ibrahim SA was the most relevant and influential author within this field. Visuals of thematic map and co-occurrences identified the basic, motor, and niche themes within the literature. Conclusions Racial and ethnic disparity within arthroplasty literature demonstrate growing traction with global contributions. United States authors and institutions are the largest contributors within this field. This bibliometric analysis identified previous, current, and future trends for prediction of future hotspots.
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Affiliation(s)
- Fong H. Nham
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, Detroit, MI, 48201, USA
| | | | - Winnie Xu
- Department of Orthopaedic Surgery, Columbia University Medical Center, USA
| | | | - Nana O. Sarpong
- Department of Orthopaedic Surgery, Columbia University Medical Center, USA
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Abella MKIL, Thorne T, Hayashi J, Finlay AK, Frick S, Amanatullah DF. An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes. Orthopedics 2024; 47:e131-e138. [PMID: 38285555 DOI: 10.3928/01477447-20240122-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].
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Gordon AM, Ng MK, Elali F, Piuzzi NS, Mont MA. A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient. J Arthroplasty 2024:S0883-5403(24)00341-3. [PMID: 38615971 DOI: 10.1016/j.arth.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care. METHODS A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant. RESULTS High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI. CONCLUSIONS Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adam M Gordon
- Questrom School of Business, Boston University, Boston, Massachusetts; Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Faisal Elali
- SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, New York
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Rubin Institute of Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Rechenmacher AJ, Case A, Wu M, Ryan SP, Seyler TM, Bolognesi MP. Outcome Disparities in Total Knee and Total Hip Arthroplasty among Native American Populations. J Racial Ethn Health Disparities 2024; 11:1106-1115. [PMID: 37036599 DOI: 10.1007/s40615-023-01590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/25/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities. METHODS This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses. RESULTS Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0). CONCLUSION AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study.
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Affiliation(s)
- Albert J Rechenmacher
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Ayden Case
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Mark Wu
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
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Rampersaud YR, Sundararajan K, Docter S, Perruccio AV, Gandhi R, Adams D, Briggs N, Davey JR, Fehlings M, Lewis SJ, Magtoto R, Massicotte E, Sarro A, Syed K, Mahomed NN, Veillette C. Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study. BMC Health Serv Res 2023; 23:1150. [PMID: 37880706 PMCID: PMC10598977 DOI: 10.1186/s12913-023-10055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.
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Affiliation(s)
- Y Raja Rampersaud
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada.
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada.
| | - Kala Sundararajan
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Shgufta Docter
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Anthony V Perruccio
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rajiv Gandhi
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Diana Adams
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - Natasha Briggs
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
| | - J Rod Davey
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Fehlings
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Rosalie Magtoto
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Eric Massicotte
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Angela Sarro
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Khalid Syed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nizar N Mahomed
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Veillette
- Division of Orthopaedic Surgery, Schroeder Arthritis Institute, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Lung BE, Donnelly MR, Callan K, McLellan M, Taka T, Stitzlein RN, McMaster WC, So DH, Yang S. Preoperative demographics and laboratory markers may be associated with early dislocation after total hip arthroplasty. J Exp Orthop 2023; 10:100. [PMID: 37801165 PMCID: PMC10558409 DOI: 10.1186/s40634-023-00659-z] [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: 03/05/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE The purpose of this study was to identify modifiable medical comorbidities, laboratory markers and flaws in perioperative management that increase the risk of acute dislocation in total hip arthroplasty (THA) patients. METHODS All THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Demographic data, preoperative laboratory values, recorded past medical history, operative details as well as outcome and complication information were collected. The study population was divided into two cohorts: non-dislocation and dislocation patients. Statistics were performed to compare the characteristics of both cohorts and to identify risk factors for prosthetic dislocation (α < 0.05). RESULTS 275,107 patients underwent primary THA in 2007 to 2020, of which 1,258 (0.5%) patients experienced a prosthetic hip dislocation. Demographics between non-dislocation and dislocation cohorts varied significantly in that dislocation patients were more likely to be female, older, with lower body mass index and a more extensive past medical history (all p < 0.05). Moreover, hypoalbuminemia and moderate/severe anemia were associated with increased risk of dislocation in a multivariate model (all p < 0.05). Finally, use of general anesthesia, longer operative time, and longer length of hospital stay correlated with greater risk of prosthetic dislocation (all p < 0.05). CONCLUSIONS Elderly female patients and patients with certain abnormal preoperative laboratory values are at risk for sustaining acute dislocations after index THA. Careful interdisciplinary planning and medical optimization should be considered in high-risk patients as dislocations significantly increase the risk of sepsis, cerebral vascular accident, and blood transfusions on readmission.
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Affiliation(s)
- Brandon E Lung
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA.
| | - Megan R Donnelly
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Kylie Callan
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Maddison McLellan
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Taha Taka
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Russell N Stitzlein
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - William C McMaster
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - David H So
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Steven Yang
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
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Piponov H, Acquarulo B, Ferreira A, Myrick K, Halawi MJ. Outpatient Total Joint Arthroplasty: Are We Closing the Racial Disparities Gap? J Racial Ethn Health Disparities 2023; 10:2320-2326. [PMID: 36100812 DOI: 10.1007/s40615-022-01411-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/30/2022] [Accepted: 09/04/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION As ne arly half of all total joint arthroplasty (TJA) procedures are projected to be performed in the outpatient setting by 2026, the impact of this trend on health disparities remains to be explored. This study investigated the racial/ethnic differences in the proportion of TJA performed as outpatient as well as the impact of outpatient surgery on 30-day complication and readmission rates. METHODS The ACS National Surgical Quality Improvement Program was retrospectively reviewed for all patients who underwent primary, elective total hip and knee arthroplasty (THA, TKA) between 2011 and 2018. The proportion of TJA performed as an outpatient, 30-day complications, and 30-day readmission among African American, Hispanic, Asian, Native American/Alaskan, and Hawaiian/Pacific Islander patients were each compared to White patients (control group). Analyses were performed for each racial/ethnic group separately. A general linear model (GLM) was used to calculate the odds ratios for receiving TJA in an outpatient vs. inpatient setting while adjusting for age, gender, body mass index (BMI), functional status, and comorbidities. RESULTS In total, 170,722 THAs and 285,920 TKAs were analyzed. Compared to White patients, non-White patients had higher likelihood of THA or TKA performed as an outpatient (OR 1.31 and 1.24 respectively for African American patients, OR 1.65 and 1.76 respectively for Hispanic patients, and OR 1.66 and 1.59 respectively for Asian patients, p < 0.001). Outpatient surgery did not lead to increased complications in any of the study groups compared to inpatient surgery (p > 0.05). However, readmission rates were significantly higher for outpatient TKA in all the study groups compared to inpatient TKA (OR range 2.47-10.15, p < 0.001). Complication and readmission rates were similar between inpatient and outpatient THA for all the study groups. CONCLUSION While this study demonstrated higher proportion of TJA performed as an outpatient among most non-White racial/ethnic groups, this observation should be tempered with the increased readmission rates observed in outpatient TKA, which could further the disparities gap in health outcomes.
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Affiliation(s)
- Hristo Piponov
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA
| | - Blake Acquarulo
- Frank H Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA
| | | | - Karen Myrick
- Frank H Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA
- Department of Nursing, University of Saint Joseph, School of Interdisciplinary Health and Science, West Hartford, CT, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA.
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Tarawneh OH, Quan T, Liu IZ, Pizzarro J, Marquardt C, Tabaie SA. Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2847-2852. [PMID: 36853514 DOI: 10.1007/s00590-023-03496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. METHODS Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. RESULTS Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. CONCLUSION Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.
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Affiliation(s)
- Omar H Tarawneh
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA.
| | - Theodore Quan
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Ivan Z Liu
- The Medical College of Georgia, Augusta University, 1120 15th St, GA, 30912, Augusta, USA
| | - Jordan Pizzarro
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Caillin Marquardt
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Sean A Tabaie
- Department of Orthopaedic Surgery, Children's National Hospital, 111 Michigan Avenue, Washington, NWDC, 20010, USA
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Livergant RJ, Stefanyk K, Binda C, Fraulin G, Maleki S, Sibbeston S, Joharifard S, Hillier T, Joos E. Post-operative outcomes in Indigenous patients in North America and Oceania: A systematic review and meta-analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001805. [PMID: 37585444 PMCID: PMC10431673 DOI: 10.1371/journal.pgph.0001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/28/2023] [Indexed: 08/18/2023]
Abstract
Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative mortality. Several gaps in data exist regarding global differences in surgical morbidity and mortality for Indigenous populations based on geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative outcomes between Indigenous and non-Indigenous populations. This systematic review and meta-analysis was conducted in accordance with PRISMA and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n = 31, North America n = 36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients had 1.26 times odds of post-operative morbidity (OR = 1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times odds of post-operative infection (OR = 1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times odds of reoperation (OR = 1.33, 95% CI: 1.02-1.74, p = 0.04). In conclusion, we found that Indigenous patients in North American and Oceania experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there is a low proportion of high-quality research focusing on assessing surgical equity for Indigenous patients in these regions, despite multiple international and national calls to action for reconciliation and decolonization to improve quality surgical care for Indigenous populations.
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Affiliation(s)
- Rachel J. Livergant
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kelsey Stefanyk
- Faculty of Medicine, University of British Columbia, Prince George, British Columbia, Canada
| | - Catherine Binda
- Faculty of Medicine, University of British Columbia, Terrace, British Columbia, Canada
| | - Georgia Fraulin
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sasha Maleki
- Faculty of Pharmaceutical Sciences, Lower Mainland Pharmacy Services, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Sibbeston
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Northwest Territory Métis Nation, Yellowknife, Northwest Territories, Canada
| | - Shahrzad Joharifard
- Department of Pediatric and Thoracic Surgery, British Columbia Children’s Hospital, University of British Columbia, Vancouver, Canada
| | - Tracey Hillier
- Mi’kmaq Qalipu First Nation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Emilie Joos
- Division of General Surgery, Branch for Global Surgical Care, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Abella MKIL, Lee AY, Kitamura RK, Ahn HJ, Woo RK. Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians. J Surg Res 2023; 288:99-107. [PMID: 36963299 DOI: 10.1016/j.jss.2023.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications. METHODS This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. RESULTS AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication. CONCLUSIONS Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Queen's Medical Center, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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11
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Abella MKIL, Lee AY, Agonias K, Maka P, Ahn HJ, Woo RK. Racial Disparities in General Surgery Outcomes. J Surg Res 2023; 288:261-268. [PMID: 37030184 DOI: 10.1016/j.jss.2023.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/21/2023] [Accepted: 03/09/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION While disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program. METHODS National Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non-home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated. RESULTS Compared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non-home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non-home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non-Hispanic White patients. Asian patients had lower odds of each adverse outcome. CONCLUSIONS Black, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non-Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non-home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Keinan Agonias
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Piueti Maka
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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12
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Chang J, Medina M, Kim SJ. Is patients' rurality associated with in-hospital sepsis death in US hospitals? Front Public Health 2023; 11:1169209. [PMID: 37383255 PMCID: PMC10294422 DOI: 10.3389/fpubh.2023.1169209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023] Open
Abstract
Background The focus of this study was to explore the association of patients' rurality and other patient and hospital-related factors with in-hospital sepsis mortality to identify possible health disparities across United States hospitals. Methods The National Inpatient Sample was used to identify nationwide sepsis patients (n = 1,977,537, weighted n = 9,887,682) from 2016 to 2019. We used multivariate survey logistic regression models to identify predictors for how patients' rurality is associated with in-hospital death. Findings During the study periods, in-hospital death rates among sepsis inpatients continuously decreased (11.3% in 2016 to 9.9% in 2019) for all rurality levels. Rao-Schott Chi-Square tests demonstrated that certain patient and hospital factors had varied in-hospital death rates. Multivariate survey logistic regressions suggested that rural areas, minorities, females, older adults, low-income, and uninsured patients have higher odds of in-hospital mortality. Further, specific census divisions like New England, Middle Atlantic, and East North Central had greater in-hospital sepsis death odds. Conclusion Rurality was associated with increased in-hospital sepsis death across multiple patient populations and locations. Further, rurality in New England, Middle Atlantic, and East North Central locations is exceptionally high odds. In addition, minority races in rural areas also have an increased odds of in-hospital death. Therefore, rural healthcare requires a more significant influx of resources and should also include assessing patient-related factors.
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Affiliation(s)
- Jongwha Chang
- Department of Pharmaceutical Sciences, Irma Lerma Rangel School of Pharmacy, Texas A&M University, College Station, TX, United States
| | - Mar Medina
- School of Pharmacy, University of Texas at El Paso, El Paso, TX, United States
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
- Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea
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13
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Aggarwal VA, Sohn G, Walton S, Sambandam S, Wukich D. Complications and Costs Associated With Ethnicity Following Total Hip Arthroplasty: A Retrospective Matched Cohort Study. Cureus 2023; 15:e40595. [PMID: 37469826 PMCID: PMC10353834 DOI: 10.7759/cureus.40595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Minority patients often have greater numbers of complications, revisions, and costs after total hip arthroplasty (THA). This study investigates how race correlates with specific surgical complications, revisions, and total costs following THA both before and after propensity matching. METHODS Data from 2014-2016 were collected from a large commercial insurance database known as PearlDiver. THA patients were assigned under Current Procedural Terminology (CPT-27130) and International Statistical Classification of Diseases (ICD-9-P-8151) codes and then divided into groups based on racial status in the database. Patients of different ethnicities including White, Black, Asian, and Hispanic patients were compared in regard to age, gender, comorbidities, lengths of stay, and surgical complications and costs at thirty days, ninety days, and one year using unequal variance t-tests. Black, Asian, and Hispanic patients are collectively referred to as minority patients. Patient comparisons were done both before and after matching for age, gender, tobacco use, diabetes, and obesity comorbidities. RESULTS A total of 73,688 White (93%), 4,822 Black (6%), 268 Asian (0.3%), and 420 Hispanic (0.5%) THA patients were included. Significantly more minority patients underwent THA under the age of 65 and had higher comorbidity indices and lengths of stay. Black patients had significantly higher complication rates, but there was no significant difference in rates of revision in any minority group. Minority patients were charged 9%-83% more. After matching, Black and Hispanic patients maintained higher comorbidity indices and lengths of stay. Black patients had a spectrum of complication rates but significantly decreased revision rates. Furthermore, after matching, minority patients were charged 5%-65% more. CONCLUSIONS Black patients experienced significantly greater rates of complications and higher total costs; whereas, Asian and Hispanic patients did not have significant differences in complications but did have higher costs. Therefore, this study aligns with previous studies and supports our hypothesis that Black ethnicity patients have worse outcomes than White ethnicity patients after THA, advocating for reducing health disparities and establishing more equitable healthcare, but does not support our hypothesis for Asian and Hispanic patients, likely due to a small study population size, warranting further research into the topic.
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Affiliation(s)
- Vikram A Aggarwal
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Garrett Sohn
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Sharon Walton
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Senthil Sambandam
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Dane Wukich
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
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Dlott CC, O'Connor MI, Wiznia DH. The Use of Race in Risk Assessment Tools Contributes to Systemic Racism. J Racial Ethn Health Disparities 2023; 10:1-3. [PMID: 36414930 DOI: 10.1007/s40615-022-01451-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/17/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Abstract
Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.
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Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
| | - Mary I O'Connor
- Movement Is Life, Washington, DC, USA.,Vori Health, Nashville, TN, USA
| | - Daniel H Wiznia
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA.,Movement Is Life, Washington, DC, USA
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15
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Magnuson JA, Griffin SA, Venkat N, Gold PA, Courtney PM, Krueger CA. Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty. Clin Orthop Relat Res 2023; 481:202-210. [PMID: 35446266 PMCID: PMC9831190 DOI: 10.1097/corr.0000000000002185] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/04/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Justin A. Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sean A. Griffin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Florida Atlantic University College of Medicine, Boca Raton, FL, USA
| | - Nitya Venkat
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Peter A. Gold
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - P. Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chad A. Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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16
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Benes GA, Dasa V, Krause PC, Jones DG, Leslie LJ, Chapple AG. Disparities in Elective and Nonelective Total Hip Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00011-6. [PMID: 36690188 DOI: 10.1016/j.arth.2023.01.011] [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: 06/07/2022] [Revised: 12/21/2022] [Accepted: 01/15/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication. METHODS Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively. RESULTS After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation. CONCLUSION Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.
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Affiliation(s)
- Gregory A Benes
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Vinod Dasa
- LSUHSC Department of Orthopedic Surgery, New Orleans, Louisiana
| | - Peter C Krause
- LSUHSC Department of Orthopedic Surgery, New Orleans, Louisiana
| | - Deryk G Jones
- Ochsner Sports Medicine Institute, Jefferson, Louisiana
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Rudisill SS, Varady NH, Birir A, Goodman SM, Parks ML, Amen TB. Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:171-187.e18. [PMID: 35985539 DOI: 10.1016/j.arth.2022.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel S Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Rush Medical College of Rush University, Chicago, Illinois
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Aseal Birir
- Harvard Medical School, Boston, Massachusetts
| | - Susan M Goodman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael L Parks
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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18
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Jackson JE, Rajasekar G, Vukcevich O, Coakley BA, Nuño M, Saadai P. Association Between Race, Gender, and Pediatric Postoperative Outcomes: An Updated Retrospective Review. J Surg Res 2023; 281:112-121. [PMID: 36155268 DOI: 10.1016/j.jss.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 08/05/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There has not been a recent evaluation of the association between racial and gender and surgical outcomes in children. We aimed to evaluate improvements in race- and gender-related pediatric postoperative outcomes since a report utilizing the Kids' Inpatient Database data from 2003 to 2006. METHODS Using Kids' Inpatient Database (2009, 2012, 2016), we identified 245,976 pediatric patients who underwent appendectomy for acute appendicitis (93.6%), pyloromyotomy for pyloric stenosis (2.7%), empyema decortication (1.6%), congenital diaphragmatic hernia repair (0.7%), small bowel resection for intussusception (0.5%), or colonic resection for Hirschsprung disease (0.2%). The primary outcome was the development of postoperative complications. Multivariable logistic regression was used to evaluate risk-adjusted associations among race, gender, income, and postoperative complications. RESULTS Most patients were male (61.5%) and 45.7% were White. Postoperative complications were significantly associated with male gender (P < 0.0001) and race (P < 0.0001). After adjustment, Black patients were more likely to experience any complication than White patients (adjusted odds ratio 1.3, confidence interval 1.2-1.4), and males were more likely than females (adjusted odds ratio 1.3, confidence interval 1.2-1.4). CONCLUSIONS No clear progress has been made in eliminating race- or gender-based disparities in pediatric postoperative outcomes. New strategies are needed to better understand and address these disparities.
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Affiliation(s)
- Jordan E Jackson
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Ganesh Rajasekar
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Olivia Vukcevich
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Brian A Coakley
- Division of Pediatric Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Payam Saadai
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California.
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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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20
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Ding Y, Feng D, Liu Y, Gao J, Wang L, Li Y, Guo Y, Tang F. The prevalence and risk factors of dislocation after primary total hip arthroplasty. Acta Orthop Belg 2022; 88:467-474. [PMID: 36791699 DOI: 10.52628/88.3.9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
This study aimed to investigate the occurrence of dislocation and risk factors following primary total hip arthroplasty (THA). Retrospective analysis was done on the clinical data of 441patients with primary total hip arthroplasty who were admitted to our hospital between May 2018 and early December 2020. A total of 294 patients without posterior soft tissue repair were included as control group, and a total of 147 patients with repair of the short external rotator muscle and joint capsule were assigned to the repair group. All operated patients were observed to analyze the occurrence and risk of early postoperative dislocation. Within 6 months after hip arthroplasty, the early hip dislocation rate in the repair group was 0.68%, which was significantly lower than that in the control group (4.78%) (P < 0.05). The results of multifactorial analysis showed that age ≥75 years, combined limb or mental illness, artificial femoral head diameter <30 mm, posterolateral approach and prosthesis placement outside the safety zone, and improper handling were risk factors for dislocation (P < 0.05); The incidence of re-dislocation was lower in the targeted intervention group (P < 0.05). The occurrence of dislocation after THA is related to age, gender, and type of orthopedic disease. The risk factors should be explored to develop targeted intervention protocol, decreasing the dislocation rate and improving the prognosis.
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21
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Upfill-Brown AM, Paisner ND, Donnelly PC, De A, Sassoon AA. Lower Rates of Ceramic Femoral Head Use in Non-White Patients in the United States, a National Registry Study. J Arthroplasty 2022; 37:S919-S924.e2. [PMID: 35307527 PMCID: PMC9386729 DOI: 10.1016/j.arth.2022.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of our study was to investigate the association of race and ethnicity with the use of the newest technology and postoperative outcomes in total hip arthroplasty (THA) using the American Academy of Orthopaedic Surgeons (AAOS) American Joint Replacement Registry (AJRR). METHODS Adult THA procedures were queried from the AJRR from 2012 to 2020. A mixed-effects multivariate regression model was used to evaluate the association of race and ethnicity with the use of the newest technology (ceramic femoral head, dual-mobility implant, and robotic assist) at 30-day, and 90-day readmission. A proportional subdistribution hazard model was used to model a risk of revision THA. RESULTS There were 85,188 THAs with complete data for an analysis of outcomes and 103,218 for an analysis of ceramic head usage. The median length of follow-up was 37.9 months (interquartile range [IQR] 21.6 to 56.3 months). In multivariate models, compared to White non-Hispanic patients, Black (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.92, P < .001), Hispanic (OR 0.76, CI 0.59-0.99, P = .037), Asian (OR 0.74, CI 0.55-1.00, P = .045), and Native American (OR 0.52, CI 0.30-0.87, P = .004) patients all had significantly lower rates of ceramic head use in THA. Compared to White non-Hispanic patients, Asian (hazard ratio [HR] 0.39, CI 0.18-0.86, P = .008) and Hispanic (HR 0.43, CI 0.19-0.98, P = .043) patients had significantly lower rates of revision. No differences in 30-day or 90-day readmission rates were seen. CONCLUSION Black, Hispanic, Native American, and Asian patients had lower rates of ceramic head use in THA when compared to White patients. These differences did not translate into worse clinical outcomes on a short-term follow-up. In fact, Asian patients had lower revision rates compared to non-Hispanic White patients. Additional study is necessary to evaluate the long-term consequence of lower ceramic head use in non-White patients in the United States.
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Affiliation(s)
| | - Noah D. Paisner
- Pacific Northwest University School of Health Sciences, Yakima, WA
| | - Patrick C. Donnelly
- American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL
| | - Ayushmita De
- American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL
| | - Adam A. Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA,Address correspondence to: Adam A. Sassoon, MD, MS, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th, Street, Suite 2100, Santa Monica, CA 90404
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22
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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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23
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Cohen-Levy WB, Lans J, Salimy MS, Melnic CM, Bedair HS. The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty. J Arthroplasty 2022; 37:S428-S433. [PMID: 35307241 DOI: 10.1016/j.arth.2022.02.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. METHODS We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. RESULTS Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. CONCLUSION Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.
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Affiliation(s)
- Wayne B Cohen-Levy
- Department of Orthopaedic Surgery, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Orthopaedic Surgery, University Hospitals/Cleveland Medical Center, Cleveland, Ohio
| | - Jonathan Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mehdi S Salimy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
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24
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Bond J, Julion WA, Reed M. Racial Discrimination and Race-Based Biases on Orthopedic-Related Outcomes: An Integrative Review. Orthop Nurs 2022; 41:103-115. [PMID: 35358128 DOI: 10.1097/nor.0000000000000830] [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: 11/25/2022] Open
Abstract
Musculoskeletal diseases often lead to functional limitations and debility. The burden of these debilitating diseases is not balanced across race and ethnicity. The Institute of Medicine (now referred to as the National Academy of Medicine) identified racial discrimination as a substantive cause of race-based health disparities for racial and ethnic minority groups. The purpose of this integrative review is to summarize the evidence on the relationship among racial discrimination, race-based implicit biases and other types of biases (e.g., gender and appearance), and orthopaedic-related outcomes. Nine studies met inclusion criteria and were included in this review. The orthopaedic outcomes addressed across the nine studies were osteoarthritis, rheumatoid arthritis, low back pain, pain tolerance, disability, and likelihood of being recommended for a total knee arthroplasty. The results reveal that experiences of racial discrimination, race-based implicit biases, and other types of biases contribute to unsatisfactory orthopaedic-related outcomes for minority groups. Orthopaedic nurses can leverage their expertise to address these disparities in orthopaedic-related outcomes across minority groups.
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Affiliation(s)
- Jerenda Bond
- Jerenda Bond, PT, DPT, Graduate College, Rush University, Chicago, IL
- Wrenetha A. Julion, PhD, MPH, RN, CNL, FAAN, Associate Dean for Equity and Inclusion, Professor, Department of Women, Children and Family Nursing, College of Nursing, Rush University, Chicago, IL
- Monique Reed, PhD, MS, RN, FAAN, Associate Professor, Department of Community, Systems and Mental Health Nursing, College of Nursing, Rush University, Chicago, IL
| | - Wrenetha A Julion
- Jerenda Bond, PT, DPT, Graduate College, Rush University, Chicago, IL
- Wrenetha A. Julion, PhD, MPH, RN, CNL, FAAN, Associate Dean for Equity and Inclusion, Professor, Department of Women, Children and Family Nursing, College of Nursing, Rush University, Chicago, IL
- Monique Reed, PhD, MS, RN, FAAN, Associate Professor, Department of Community, Systems and Mental Health Nursing, College of Nursing, Rush University, Chicago, IL
| | - Monique Reed
- Jerenda Bond, PT, DPT, Graduate College, Rush University, Chicago, IL
- Wrenetha A. Julion, PhD, MPH, RN, CNL, FAAN, Associate Dean for Equity and Inclusion, Professor, Department of Women, Children and Family Nursing, College of Nursing, Rush University, Chicago, IL
- Monique Reed, PhD, MS, RN, FAAN, Associate Professor, Department of Community, Systems and Mental Health Nursing, College of Nursing, Rush University, Chicago, IL
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25
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Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Rev 2022; 10:01874474-202203000-00003. [PMID: 35231001 DOI: 10.2106/jbjs.rvw.21.00161] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paul M Alvarez
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John F McKeon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew I Spitzer
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Matthew Pigott
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mengnai Li
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sravya P Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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26
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Gatto AP, Feeley BT, Lansdown DA. Low socioeconomic status worsens access to care and outcomes for rotator cuff repair: a scoping review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:26-34. [PMID: 37588282 PMCID: PMC10426503 DOI: 10.1016/j.xrrt.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Poor socioeconomic status (SES) is consistently associated with poor quality of health care, particularly in the field of orthopedics. Expanding insurance coverage has created a larger patient population by specifically making health care more accessible, translating to greater demand for care in the low-SES population. The purpose of this article is to provide a scoping review of literature observing access and outcomes of rotator cuff repair surgery among low-SES populations. Methods We performed a systematic review of articles using PubMed, Embase, and EBSCO (May 2021) from 2010 onward. Peer-reviewed articles that recorded at least one SES measure specific to patients who underwent rotator cuff repair from the United States were included. SES measures were methodically defined as income, occupation, employment, education, and race. All data that aligned with these SES measures were extracted. Results Of the 1009 titles reviewed, 109 studies were screened by abstract, 23 were reviewed in full, and 7 studies met criteria for inclusion. Of the 5 studies investigating access, all 5 found disparities among postoperative physical therapy, orthopedic consult, and surgery, using Medicaid status as a proxy for income in addition to other income measures. Of the 3 studies analyzing outcomes, 2 found that low-SES patients had worse pain and function, again based on Medicaid status and other income measures. Education did not have a significant impact on outcomes, as per the 1 study that included it. No studies included measures of occupation or employment. Conclusion Patients of low SES face reduced access to cuff repair care and worse associated outcomes, despite federal and state government efforts to reduce health care disparity through health care reform. The small nature of this review reflects how measures of SES are often not examined in rotator cuff repair studies.
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Affiliation(s)
- Andrew P. Gatto
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian T. Feeley
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Drew A. Lansdown
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, USA
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
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Hartnett DA, Brodeur PG, Kosinski LR, Cruz AI, Gil JA, Cohen EM. Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty. J Arthroplasty 2022; 37:213-218.e1. [PMID: 34748913 DOI: 10.1016/j.arth.2021.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/02/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis. METHODS From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA. RESULTS Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001). CONCLUSION THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.
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Affiliation(s)
- Davis A Hartnett
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Peter G Brodeur
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Lindsay R Kosinski
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric M Cohen
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization. J Arthroplasty 2021; 36:3845-3849. [PMID: 34479764 DOI: 10.1016/j.arth.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/23/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Racial disparities surrounding the utilization of total hip and total knee arthroplasty (THA, TKA) are well documented. The Implicit Association Test (IAT) is a validated tool used to measure implicit and explicit bias. The purpose of this study is to evaluate if variations in IAT scores by geographical region in the United States (US) correspond with regional variations in THA and TKA utilization by blacks compared to whites. METHODS Data from the US Census and National Inpatient Sample from 2012 to 2014 were used to calculate THA and TKA utilization rates among Medicare-aged blacks and whites. Data were aggregated by US Census Bureau Division. Regional implicit bias was assessed by calculating a weighted average of IAT scores for each division. RESULTS Across all geographic regions and years, the surveyed population demonstrated an implicit bias favoring whites over blacks. The population adjusted ratio of white-to-black utilization of THA and TKA by geographic division varied between 0.86-1.85 and 0.87-2.01, respectively. The difference in utilization between geographic divisions reached statistical significance (P < .001). No correlation was found between the IAT scores and race-specific utilization ratios among geographic divisions. CONCLUSION Implicit bias as measured by regional IAT did not reflect THA and TKA utilization disparities. The racial disparity in utilization of THA and TKA significantly varied between divisions. The observed disparity was greater in divisions with a relatively higher proportion of blacks. To the authors' knowledge, this is the first study to evaluate the impact of implicit bias on utilization of THA and TKA.
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29
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Kamaraju A, Feinn R, Myrick K, Halawi MJ. Total Versus Unicondylar Knee Arthroplasty: Does Race Play a Role in the Treatment Selection? J Racial Ethn Health Disparities 2021; 9:1845-1849. [PMID: 34327668 DOI: 10.1007/s40615-021-01120-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Racial disparities have been well reported in the utilization and outcomes of knee arthroplasty, but it is unclear whether disparities also extend to the choice of surgical treatment. The primary objective of this study is to identify if race plays a role in the selection of unicondylar versus total knee arthroplasty (UKA, TKA) for isolated tibiofemoral osteoarthritis (OA). A secondary objective is to identify the differences in the complication rates for each procedure by racial identity. METHODS A retrospective review of the 2006-2018 American College of Surgeons National Surgical Quality Improvement Program was performed. Asian, Black, Hawaiian/Pacific Islander, Hispanic, Native American/Alaskan, and White individuals who underwent primary elective UKA or TKA were compared in terms of UKA vs. TKA utilization rates and outcomes. RESULTS A total of 308,715 patients were analyzed. After controlling for all baseline differences, Whites (3.5%), Asians (3.7%), and Hawaiian/Pacific Islanders (3.1%) had around twice the rate of UKA compared to Blacks (1.6%), while Hispanics (2.1%) and Native American/Alaskans (1.7%) were in between (p <0.001). TKA was associated with higher complications compared to UKA in all racial groups (p < 0.001). CONCLUSION Minority patients, especially Blacks, were less likely to receive UKA for treatment of isolated knee OA. This is significant because treatment selection in patients who are eligible for UKA can have a significant impact on postoperative recovery and complications rates.
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Affiliation(s)
- Anya Kamaraju
- Frank H Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA
| | - Richard Feinn
- Frank H Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA
| | - Karen Myrick
- Frank H Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA.,University of Saint Joseph, Hartford, West, CT, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA.
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30
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Dharmasukrit C, Chan SYS, Applegate RL, Tancredi DJ, Harvath TA, Joseph JG. Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis. J Arthroplasty 2021; 36:1895-1903. [PMID: 33573811 DOI: 10.1016/j.arth.2021.01.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/21/2020] [Accepted: 01/13/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although frailty has been shown to be associated with adverse outcomes in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), prior studies have not examined how race/ethnicity might moderate these associations. We aimed to assess race/ethnicity as a potential moderator of the associations of frailty and functional status with arthroplasty outcomes. METHODS The National Surgical Quality Improvement Program was queried for patients who underwent THA or TKA from 2011 to 2017. Frailty was assessed using the modified frailty index. Regression analyses were conducted to examine associations connecting frailty/functional status with 30-day readmission, adverse discharge, and length of stay (LOS). Further analyses were conducted to investigate race/ethnicity as a potential moderator of these relationships. RESULTS We identified 219,143 TKA and 130,022 THA patients. Frailty and nonindependent functional status were positively associated with all outcomes (P < .001). Compared to White non-Hispanic patients, Black non-Hispanic patients had higher odds for all outcomes after TKA (P < .001) and for adverse discharge/longer LOS after THA (P < .001). Similar associations were observed for Hispanics for the adverse discharge/LOS outcomes. Race/ethnicity moderated the effects of frailty in TKA for all outcomes and in THA for adverse discharge/LOS. Race/ethnicity moderated the effects of nonindependent function in TKA for adverse discharge/LOS and on LOS alone for THA. CONCLUSION Disparities for Black non-Hispanic and Hispanic patients persist for readmission, adverse discharge, and LOS. However, the effects of increasing frailty and nonindependent functional status on these outcomes were the most pronounced among White non-Hispanic patients.
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Affiliation(s)
- Charlie Dharmasukrit
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA
| | - Sut Yee Shirley Chan
- Psychology Department, Asian American Center on Disparities Research, University of California, Davis, Davis, CA
| | - Richard L Applegate
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics and Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
| | - Theresa A Harvath
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA
| | - Jill G Joseph
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA
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31
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Hunter DJ, March L, Chew M. Osteoarthritis in 2020 and beyond - Authors' reply. Lancet 2021; 397:1060. [PMID: 33743864 DOI: 10.1016/s0140-6736(21)00205-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Affiliation(s)
- David J Hunter
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, University of Sydney and Institute of Bone and Joint Research, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW 2065, Australia; Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
| | - Lyn March
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, University of Sydney and Institute of Bone and Joint Research, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW 2065, Australia
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