Disparities in Discharge Destination After Lower Extremity Joint Arthroplasty: Analysis of 7924 Patients in an Urban Setting

A bibliometric analysis of the top 50 cited studies related to acromioclavicular joint instability

Background

Acromioclavicular joint (ACJ) injury is a common orthopaedic condition accounting for over 40 % of all shoulder injuries. The purpose of this study is to assess the research trends and characteristics of the top 50 cited articles on ACJ instability.

Methods

A systematic search was conducted in Web of Science to identify articles primarily related to ACJ injury or instability. Characteristics including citation number, country of origin, journal and institution of publication, impact factor, authorship, level of evidence, patient demographics, and study type were analyzed and recorded.

Results

Research output on ACJ instability has been steadily increasing, with the top 50 cited studies predominantly presenting Level IV evidence. These studies primarily focused on treatment outcomes which included predominantly male patients and exhibited a large variation in citation counts. The American Journal of Sports Medicine was the most productive journal, and the USA was the most productive nation.

Conclusion

There is an increasing number of publications in the ACJ instability literature, primarily concentrated in a few institutions and journals, and focusing mainly on treatment outcomes. A significant portion of these publications are of low scientific quality, and there is a notable lack of research on outcomes for females.

Neighborhood income inequality associated with functional independence after ischemic stroke: a cohort study

BACKGROUND

Individual measures of socioeconomic status have been associated with post-stroke disability in patients with ischemic stroke. However, it is not known whether the distribution of income in a community may have an impact on stroke recovery. We hypothesized that increased neighborhood income inequality (as measured by the Gini index) may be associated with a slower recovery after stroke.

METHODS

This was a retrospective cohort study of adult patients hospitalized at a comprehensive stroke center with acute ischemic stroke between 1/1/2018-12/31/2019. Individual patient data was abstracted from the EHR, and zip code Gini index was obtained from the US Census Bureau. Binary logistic regression was used to assess the relationship between Gini index and functional independence (modified Rankin scale ≤2) at discharge and first outpatient follow-up. These models controlled for patient demographics, stroke risk factors, stroke severity, and stroke treatment. A second binary regression was also performed using a subset of patients to assess possible predictors of being discharged as recommended (i.e. having a discharge destination that was consistent with the recommendation of the inpatient medical team).

RESULTS

Three hundred and thirty-seven patients were included in this analysis. The median time to first outpatient follow-up was 35 days. Zip code Gini index was not associated with functional independence at discharge but was associated with independence at follow-up (modified Rankin scale ≤2) such that patients from higher inequality neighborhoods had decreased odds of being independent. More specifically, each 1% increase in neighborhood Gini index was associated with 8% decreased odds of independence at follow-up (OR=0.923, 95% CI: 0.863-0.987). Being discharged as recommended was associated with increased odds of independence at follow-up (OR=3.359, 95% CI: 1.055-10.695). Greater income inequality (OR=0.909, 95% CI: 0.841-0.983) and Asian race (OR=0.093, 95% CI: 0.011-0.766) were associated with decreased odds of being discharged as recommended.

CONCLUSION

Among a cohort of patients with ischemic stroke, increased neighborhood income inequality was associated with decreased odds of achieving functional independence up (modified Rankin scale ≤2) by the time of first outpatient follow-up (at a median of 35 days following discharge). This disparity may be driven by discharge destination and race.

Neighborhood Socioeconomic Disadvantage is Associated With Increased Health Care Utilization After Septic and Aseptic Revision Total Hip Arthroplasty

BACKGROUND

A greater area deprivation index (ADI), a tool that gauges socioeconomic disadvantage at the neighborhood level, is associated with worse health care outcomes following primary total hip arthroplasty. However, its association with revision total hip arthroplasty (rTHA) is unknown. This study aimed to determine the association between ADI and rates of postoperative health care resource utilization following rTHA.

METHODS

A total of 996 patients who underwent rTHA between 2016 and 2022 were enrolled in a prospective study. The primary outcomes assessed were nonhome discharge disposition (DD), length of stay (LOS) ≥ three days, 90-day emergency department (ED) visits, and 90-day hospital readmissions. The ADI was calculated using the patient's home address at the time of surgery, with greater ADI indicating greater socioeconomic disadvantage. We evaluated the mediation effect of patient race on ADI and postoperative health care utilization using a multivariable logistic regression model.

RESULTS

A higher median ADI was revealed for patients who experienced nonhome discharge (P = 0.001), extended LOS (P < 0.001), and ED readmission within 90 days of surgery (P = 0.045). When comparing septic versus aseptic rTHA patients, there were significant differences in health care resource utilization but no difference in ADI between the two groups. For aseptic rTHA, ADI significantly mediated the effect of race on both nonhome DD and LOS ≥ 3 (41 and 46% mediation, respectively). In septic rTHA, ADI mediated 31.1% of the effect of race on nonhome DD, but showed minimal mediation effect on LOS. The mediation effect of ADI on ED admission and hospital readmission was minimal for both groups.

CONCLUSIONS

Higher ADI scores are associated with increased health care utilization after rTHA, including longer hospital stays and more nonhome discharges. The ADI significantly mediates the effect of race on these outcomes, particularly in aseptic rTHA cases, suggesting that neighborhood socioeconomic factors play a crucial role in previously observed racial disparities.

Impacts of neighborhood deprivation on septic and aseptic revision total knee arthroplasty outcomes: A comprehensive analysis using the area deprivation index

BACKGROUND

Community deprivation has been linked to poor health outcomes following primary total knee arthroplasty (pTKA), but few studies have explored revision TKA (rTKA). The present study analyzed implications of neighborhood deprivation on rTKA outcomes by characterizing relationships between Area Deprivation Index (ADI) and (1) non-home discharge disposition (DD), (2) hospital length of stay (LOS), (3) 90-day emergency department (ED) visits, (4) 90-day hospital readmissions, and (5) the effect of race on these healthcare outcomes.

METHODS

A total of 1,434 patients who underwent rTKA between January 2016 and June 2022 were analyzed. Associations between the ADI and postoperative healthcare resource utilization outcomes were evaluated using multivariate logistic regression. Mediation effect was estimated using a nonparametric bootstrap resampling method.

RESULTS

Greater ADI was associated with non-home DD (p < 0.001), LOS ≥ 3 days (p < 0.001), 90-day ED visits (p = 0.015), and 90-day hospital readmission (p = 0.002). Although there was no significant difference in ADI between septic and aseptic patients, septic patients undergoing rTKA were more likely to experience non-home discharge (p < 0.001), prolonged LOS (p < 0.001), and 90-day hospital readmission (p = 0.001). The effect of race on non-home DD was found to be mediated via ADI (p = 0.038). Similarly, results showed the effect of race on prolonged LOS was mediated via ADI (p = 0.01).

CONCLUSION

A higher ADI was associated with non-home discharge, prolonged LOS, 90-day ED visits, and 90-day hospital readmissions. The impacts of patient race on both non-home discharge and prolonged LOS were mediated by ADI. This index allows clinicians to better understand and address disparities in rTKA outcomes.

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

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.

Post-Acute Care Trends and Disparities After Joint Replacements in the United States, 1991-2018: A Systematic Review

OBJECTIVE

To review evidence on post-acute care (PAC) use and disparities related to race and ethnicity and rurality in the United States over the past 2 decades among individuals who underwent major joint replacement (MJR).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

We included studies that examined US PAC trends and racial and ethnic and/or urban vs rural differences among individuals who are aged ≥18 years with hospitalization after MJR.

METHODS

We searched large academic databases (PubMed, CINAHL, Embase, Web of Science, and Scopus) for peer-reviewed, English language articles from January 1, 2000, and January 26, 2022.

RESULTS

Seventeen studies were reviewed. Studies (n = 16) consistently demonstrated that discharges post-MJR to skilled nursing facilities (SNFs) or nursing homes (NHs) decreased over time, whereas evidence on discharges to inpatient rehab facilities (IRFs), home health care (HHC), and home without HHC services were mixed. Most studies (n = 12) found that racial and ethnic minority individuals, especially Black individuals, were more frequently discharged to PAC institutions than white individuals. Demographic factors (ie, age, sex, comorbidities) and marital status were not only independently associated with discharges to institutional PAC, but also among racial and ethnic minority individuals. Only one study found urban-rural differences in PAC use, indicating that urban-dwelling individuals were more often discharged to both SNF/NH and HHC than their rural counterparts.

CONCLUSIONS AND IMPLICATIONS

Despite declines in institutional PAC use post-MJR over time, racial and minority individuals continue to experience higher rates of institutional PAC discharges compared with white individuals. To address these disparities, policymakers should consider measures that target multimorbidity and the lack of social and structural support among socially vulnerable individuals. Policymakers should also consider initiatives that address the economic and structural barriers experienced in rural areas by expanding access to telehealth and through improved care coordination.

Neighborhood socioeconomic disadvantages associated with increased rates of revisions, readmissions, and complications after total joint arthroplasty

INTRODUCTION

Low socioeconomic status based on neighborhood of residence has been suggested to be associated with poor outcomes after total joint arthroplasty (TJA). The area deprivation index (ADI) is a scale that ranks (zero to 100) neighborhoods by increasing socioeconomic disadvantage and accounts for median income, housing type, and family structure. We sought to examine the potential differences between high (national median ADI = 47) and low ADI among TJA recipients at a single institution. Specifically, we assessed: (1) 30-day emergency department visits/readmissions; (2) 90-day and 1-year revisions; as well as (3) medical and surgical complications.

METHODS

A consecutive series of primary TJAs from September 21, 2015, through December 29, 2021, at a tertiary healthcare system were reviewed. A total of 3,024 patients who had complete ADI data were included. Patients were divided into groups below the national median ADI of 47 (n = 1,896) and above (n = 1,128). Multivariable regressions to determine independent risk factors accounting for ADI, race, age, sex, American Society of Anesthesiologists Classification grade, body mass index, diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease, hypertension, chronic kidney disease, alcohol abuse, substance abuse, and tobacco use. The primary outcomes of interest include evaluation of the independent association of ADI with total postoperative complications (at 30 days, 90 days, and 1 year) after adjusting for multiple relevant cofactors.

RESULTS

After adjusting for multiple relevant cofactors, at 90 days, ADI > 47 (OR, 1.36, 95% CI 1.00-1.83, P = 0.04), men versus women (OR, 0.73, 95% CI 0.54-0.99, P = 0.039), and CHF (OR, 1.90, 95% CI 1.18-3.06, P = 0.009) were independently associated with increased total complications. The ADI was not associated with increased total complications at 30 days or 1-year (All P > 0.05).

CONCLUSION

Our findings of higher complications of the ADI > 47 cohort at 90 days, reaffirm the complex relationship between ADI, patient demographics, and additional socioeconomic parameters that may influence postoperative outcomes and complications after TJA. This study utilizing ADI demonstrates potential areas of intervention and further investigation for assessing arthroplasty outcomes.

Low Household Income Increases Hospital Length of Stay and Decreases Home Discharge Rates in Lumbar Fusion

STUDY DESIGN

Retrospective Matched Cohort Study.

OBJECTIVES

Low median household income (MHI) has been correlated with worsened surgical outcomes, but few studies have rigorously controlled for demographic and medical factors at the patient level. This study isolates the relationship between MHI and surgical outcomes in a lumbar fusion cohort using coarsened exact matching.

METHODS

Patients undergoing single-level, posterior lumbar fusion at a single institution were consecutively enrolled and retrospectively analyzed (n = 4263). Zip code was cross-referenced to census data to derive MHI. Univariate regression correlated MHI to outcomes. Patients with low MHI were matched to those with high MHI based on demographic and medical factors. Outcomes evaluated included complications, length of stay, discharge disposition, 30- and 90 day readmissions, emergency department (ED) visits, reoperations, and mortality.

RESULTS

By univariate analysis, MHI was significantly associated with 30- and 90 day readmission, ED visits, reoperation, and non-home discharge, but not mortality. After exact matching (n = 270), low-income patients had higher odds of non-home discharge (OR = 2.5, P = .016) and higher length of stay (mean 100.2 vs 92.6, P = .02). There were no differences in surgical complications, ED visits, readmissions, or reoperations between matched groups.

CONCLUSIONS

Low MHI was significantly associated with adverse short-term outcomes from lumbar fusion. A matched analysis controlling for confounding variables uncovered longer lengths of stay and higher rates of discharge to post-acute care (vs home) in lower MHI patients. Socioeconomic disparities affect health beyond access to care, worsen surgical outcomes, and impose costs on healthcare systems. Targeted interventions must be implemented to mitigate these disparities.

Marital Status, Race, Insurance Type, and Socioeconomic Status-Assessment of Social Predictors for Outcomes After Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to investigate the effect of various social determinants of health on outcomes and dispositions after total knee arthroplasty (TKA).

METHODS

A retrospective review was conducted on 14,462 consecutive TKA procedures between 2013 and 2021 at a multicenter hospital system. Data abstraction was done by inquiry to the Michigan Arthroplasty Registry Collaborative Quality Initiative. Data points requested included basic demographics, marital status, race, insurance status, socioeconomic status measured by the Area of Deprivation Index, perioperative course, and incidence of emergency department (ED) visits and readmissions within 3 months of surgery. Subsequent multivariate analyses were conducted.

RESULTS

Unmarried patients required markedly greater lengths of hospital stay and had an increased rate of discharge to skilled nursing facilities and a higher likelihood of any purpose ED visit within 90 days of surgery compared with married patients, who had a significantly greater rate of same-day discharge ( P < 0.001). Race did not markedly correlate with outcomes. Medicare patients showed a greater rate of same-day discharge, nonhome discharge, and 90-day ED visits compared with privately insured patients ( P < 0.001). Medicaid patients were more likely than privately insured patients to have a 90-day ED visit ( P < 0.001). Socioeconomic status had a minimal clinical effect on all studied outcomes.

CONCLUSION

Social factors are important considerations in understanding outcomes after TKA. Additional investigations are indicated in identifying at-risk patients and subsequent optimization of these patients.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries

BACKGROUND

The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures.

METHODS

A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05.

RESULTS

There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay.

CONCLUSIONS

Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities.

LEVEL OF EVIDENCE

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

Marginalization Influences Access, Outcomes, and Discharge Destination Following Total Joint Arthroplasty in Canada's Universal Healthcare System

BACKGROUND

The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes.

METHODS

This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores.

RESULTS

The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046).

CONCLUSION

Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility.

LEVEL OF EVIDENCE

IV.

Postoperative Discharge Destination Impacts 30-Day Outcomes: A National Surgical Quality Improvement Program Multi-Specialty Surgical Cohort Analysis

Surgical patients can be discharged to a variety of facilities which vary widely in intensity of care. Postoperative readmissions have been found to be more strongly associated with post-discharge events than pre-discharge complications, indicating the importance of discharge destination. We sought to evaluate the association between discharge destination and 30-day outcomes. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were dichotomized based on discharge destination: home versus non-home. The main outcome of interest was 30-day unplanned readmission. The secondary outcomes included post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. In this cohort study of over 1.5 million patients undergoing common surgical procedures across eight surgical specialties, we found non-home discharge to be associated with adverse 30-day post-operative outcomes, namely, unplanned readmissions, post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. Non-home discharge is associated with worse 30-day outcomes among patients undergoing common surgical procedures. Patients and caregivers should be counseled regarding discharge destination, as non-home discharge is associated with adverse post-operative outcomes.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database

BACKGROUND

The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups.

METHODS

This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates.

RESULTS

Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites.

CONCLUSION

There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health.

LEVEL OF EVIDENCE

III, retrospective cohort study.

In-Hospital Mortality Risk and Discharge Disposition Following Hip Fractures: An Analysis of the Texas Trauma Registry

Background

In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations.

Objective

Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures.

Methods

A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions.

Results

There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method.

Conclusion

Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BACKGROUND

This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.

METHODS

A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).

RESULTS

Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.

CONCLUSION

Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress.

SUMMARY OF BACKGROUND DATA

Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs.

METHODS

A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05.

RESULTS

A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228).

CONCLUSION

Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes.

LEVEL OF EVIDENCE

Level IV.

Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database

BACKGROUND

Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear.

QUESTIONS/PURPOSES

(1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA?

METHODS

Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race.

RESULTS

After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001).

CONCLUSION

These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty

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.

Racial and Ethnic Disparities in Short-Stay Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to understand racial and ethnic disparities in hospital-based, Medicare-defined outpatient total knee arthroplasty (TKA). We aimed to determine the following: 1) whether there are differences in preoperative characteristics or postoperative outcomes in outpatient TKA between racial/ethnic groups and 2) trends in outpatient TKA volume, based on race/ethnicity.

METHODS

This was a retrospective cohort study of a large national database. Outpatient TKAs performed between 2012 and 2018 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were compared between White, Black, Asian, and Hispanic patients.

RESULTS

Of 54,183 outpatient patients, 85.6% were White, 7.4% Black, 2.6% Asian, and 4.1% Hispanic. Black patients had the highest body mass index, and there were higher rates of diabetes among all minority groups (P < .001). All minority groups were more likely to be discharged to a rehabilitation or a skilled care facility compared to White patients (P < .001). Annual percentage increases in outpatient TKA were most pronounced for Asians and Hispanics and least pronounced among Blacks, when compared to White patients.

CONCLUSION

The outcomes of outpatient TKA are impacted by risk factors that reflect underlying disparities in healthcare. As joint arthroplasties have come off the inpatient-only list and procedures move to ambulatory settings, these disparities will likely magnify and impact outcomes, costs, and access points. Extensive preoperative optimization and interventions that target medical and social factors may help to reduce these disparities in TKA and increase access among minority patients.

LEVEL OF EVIDENCE

III, retrospective cohort study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Impact of social disadvantage among total knee arthroplasty places of service on procedural volume: a nationwide Medicare analysis

INTRODUCTION

As recent analyses have indicated that low-volume hospitals experience higher rates of complications following total knee arthroplasty (TKA), it remains important to evaluate how area deprivation index (ADI) of hospitals impacts the quantity of TKA performed. Our analysis sought to evaluate how the ADI of orthopedic surgeon's place of service influences TKA utilization.

MATERIALS AND METHODS

The Medicare Provider Utilization and Payment Data Public Use File (MPUP-PUF) was queried to identify claims between 2013 and 2019 associated with Healthcare Common Procedure Coding System (HCPCS) code 27447 (TKA). The MPUP-PUF file was linked with publicly available ADI information as well as information regarding each provider's practice location. The Mann-Kendall trend test was used to analyze significant differences in TKA volume between ADI quintiles and differences in TKA volume overall between the years 2013 and 2019. An adjusted multivariable linear regression analysis was conducted to evaluate how ADI, and practice-specific characteristics, influenced TKA utilization volume.

RESULTS

When isolating by ADI quintiles, no significant changes in TKA volume were demonstrated for Quintile 4 (Kendall's τ = 0.524; p = 0.13) and Quintile 5 (Kendall's τ = 0.524; p = 0.13) between 2013 and 2019. However, a significant increase in TKA volume over the study period was observed in Quintile 1 (Kendall's τ = 0.714 p = 0.034), Quintile 2 (Kendall's τ = 0.714 p = 0.034), and Quintile 3 (Kendall's τ = 0.905 p = 0.007). The adjusted multivariable linear regression model demonstrated that each increase in ADI quintile was associated with significantly lower TKA utilization (β-estimate - 1.16; 95% CI - 2.04 to - 0.29; p = 0.009).

CONCLUSIONS

Our findings suggest that resource deprivation contributes to disparities in TKA utilization. With the ongoing recognition of how social and neighborhood-level deprivation may influence access to end-stage osteoarthritis care and related perioperative outcomes, the present study serves to encourage continued efforts at ensuring equity in orthopedic care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities

Background

Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty.

Methods

A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, “disparities”, “arthroplasty”, “income”, “insurance”, “outcomes”, and “hospital volume” in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data.

Results

A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients.

Conclusion

This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients’ access to, utilization of, and outcomes after TJA.

Level of evidence

IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-022-00137-4.

Enhanced Preoperative Education Pathways: A Step Toward Reducing Disparities in Total Joint Arthroplasty Outcomes

BACKGROUND

Patients with increased comorbidities, lower socioeconomic status, and African American (AA) race have been shown to be at increased risk for suboptimal outcomes after total joint arthroplasty (TJA). Despite the body of evidence highlighting these disparities, few interventions aimed at improving outcomes specifically in high-risk patients have been evaluated. This study evaluates the impact of an enhanced preoperative education pathway (EPrEP) on outcomes after TJA.

METHODS

All patients included underwent unilateral primary total hip or knee arthroplasty at a single institution from September 1, 2020 to September 31, 2021. This is a retrospective observational cohort study comparing demographics, comorbidities, and outcomes of patients treated through EPrEP with those receiving routine care. Subgroup analysis of outcome differences by race was performed.

RESULTS

In total, 1,716 patients were included in the study: 802 went through the EPrEP and 914 did not. EPrEP patients had a higher comorbidity burden as measured by the Charlson Comorbidity Index (3.54 ± 1.71 vs 3.25 ± 1.75, P < .001). After risk adjustment, there was no significant relationship among EPrEP utilization and length of stay, home discharge, or 30-day readmissions. However, EPrEP patients were less likely to return to the emergency department 30 days postoperatively (odds ratio 0.49, 95% confidence interval 0.27-0.86, P = .016). No significant differences in outcomes between AA and non-AA patients were observed.

CONCLUSION

High-risk patients receiving individualized nurse navigator counseling experienced similar outcomes to the broader patient population undergoing TJA. Implementation of EPrEPs may be an effective means of enhancing the equity of care quality across all patients undergoing TJA.

Neighborhood Socioeconomic Disadvantages Associated With Prolonged Lengths of Stay, Nonhome Discharges, and 90-Day Readmissions After Total Knee Arthroplasty

BACKGROUND

Low socioeconomic status and neighborhood context has been linked to poor health care outcomes after total knee arthroplasty (TKA). The area deprivation index (ADI) addresses this relationship by ranking neighborhoods by socioeconomic disadvantage. We examined the following relationships of the ADI among TKA recipients: (1) patient demographics, (2) lengths of stay (LOS), (3) nonhome discharges, and (4) 90-day readmissions, emergency department visits, and reoperations.

METHODS

We reviewed a consecutive series of primary TKAs from 2018 through 2020 at a tertiary health care system. A total of 3928 patients who had complete ADI data were included. A plurality of patients (14.9%) were categorized within ADI 31-40, below the national median ADI of 47. Associations between the national ADI decile and 90-day postoperative health care utilization metrics were evaluated using multivariate regressions (adjusted for patient demographics and comorbidities).

RESULTS

The 91-100 ADI cohort was disproportionately African American, female, younger, and smokers. Compared with ADI 31-40 (reference), the ADI 61-70 cohort was associated with higher odds of LOS ≥3 days (odds ratio [OR] = 1.6 [1.08-2.36], P = .019) and nonhome discharges (OR = 1.73 [1.08-2.75], P = .021). The ADI 91-100 cohort was associated with the highest odds of prolonged LOS (OR = 2.27; [1.47-3.49], P < .001), nonhome discharges (OR = 3.49 [2.11-5.78], P < .001), and all-cause readmissions (OR: 1.79, [1.02-3.14], P = .044). No significant associations were found between the ADI and 90-day emergency department visits or reoperations (P > .05).

CONCLUSION

A higher ADI was associated with prolonged LOS, nonhome discharge status, and 90-day readmissions after TKA. This index highlights potential areas of intervention for assessing health care outcomes.

Does Dual-Eligible Medicare/Medicaid Insurance Status as a Surrogate for Socioeconomic Status Compromise Total Knee Arthroplasty Outcomes?

BACKGROUND

Medicare/Medicaid dual-eligible patients who undergo primary total knee arthroplasty (TKA) demonstrate poor outcomes when compared to patients with other payers. We compare Medicare/Medicaid dual-eligible patients vs Medicare and Medicaid only patients at a single hospital center.

METHODS

All patients who underwent TKA for aseptic arthritis between August 9, 2016 and December 30, 2020 with either Medicare or Medicaid insurance were retrospectively reviewed. 4599 consecutive TKA (3749 Medicare, 286 Medicare/Medicaid dual eligibility, and 564 Medicaid) were included. Groups were compared using appropriate tests for direct comparisons and regression analysis.

RESULTS

Patients with dual eligibility and Medicaid insurance were less likely to be white and married, more likely to be female and current smokers, and more likely to have COPD, mild liver disease, diabetes mellitus, malignancy, and HIV/AIDS, but had a lower age-adjusted Charleson Comorbidity Index when compared to Medicare patients. When controlling for smoking status and medical comorbidities, patients with dual eligibility and Medicaid insurance stayed in the hospital 0.64 and 0.39 additional days (P < .001), respectively, were more likely to be discharged to subacute rehab (RR 2.01, 1.49, P < .001) and acute rehab (RR 2.22, 2.46, P = .007, < .001), and were 2.14 and 1.73 times more likely to return to the ED within 90 days (P < .001) compared to Medicare patients.

CONCLUSION

Value-based healthcare may disincentivize treating patients with low socioeconomic status, represented by Medicaid and dual-eligible insurance status, by their association with increased postoperative healthcare utilization, and less risky patients may be prioritized.

Analysis of Risk Factors for High-Risk Patients Undergoing Total Joint Arthroplasty

Background

The purpose of this study is to evaluate and redefine patients at high risk for increased resource utilization and complications after total joint arthroplasty (TJA), so interventions may focus on patients standing to receive the most benefit.

Material and methods

This is a retrospective study of 787 patients undergoing primary unilateral TJA from September 1, 2020, to September 31, 2021. Patients were deemed to be at “high risk” based on criteria derived from published literature and triaged to an enhanced preoperative education program. Patients that were discharged to a skilled nursing facility, had a length of stay ≥ 2 days, returned to the emergency department, or readmitted within 30 days were classified as having a composite outcome. A univariate analysis compared patients who did and did not experience the composite outcome, and multivariate regression was performed to evaluate predictors of this endpoint.

Results

Differences in rates of 5 of the 28 risk factors were present between patients who did and did not experience composite outcomes. After controlling for other factors, African American race, planned discharge to skilled nursing facility, mental health conditions or drug use, cardiac, and neurologic conditions were predictive of the composite outcome. Patients who were reclassified as “high risk” with 1 or more of these characteristics, experienced longer length of stay and lower rates of home discharge than the rest of the population.

Conclusion

This study presents a profile of high-risk TJA patients that can be incorporated into clinical practice for risk stratification and targeted intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

The Predictive Accuracy of the CareMOSAIC Risk Assessment for Discharge Disposition in Medicare Bundle Patients After Total Joint Arthroplasty

Background

This article evaluates the predictive accuracy of the CareMOSAIC Risk Assessment for discharge disposition in Medicare patients undergoing total joint arthroplasty.

Methods

Retrospectively collected data from a single institution on 499 consecutive Medicare patients who underwent primary total hip arthroplasty or total knee arthroplasty were reviewed. The CareMOSAIC Risk Assessment was completed by each patient during the preoperative period. The CareMOSAIC Risk Assessment scores were calculated via the CareMOSAIC software, and the scores indicate a risk category for each patient as it relates to post–acute care discharge needs.

Results

The CareMOSAIC Risk Assessment with a binary logistic regression area under the receiver operating characteristic curve of 0.798 appears to be a reliable tool for predicting discharge disposition. The assessment had a positive predictive value of 90.0% and negative predictive value of 76.3% for discharge disposition.

Conclusions

The CareMOSAIC Risk Assessment effectively predicts the discharge disposition for Medicare patients undergoing total hip or total knee arthroplasty.

1-year trajectories of patients undergoing primary total hip arthroplasty: Patient reported outcomes and resource needs according to education level

Background

Objectives were first to evaluate by education level one-year trajectories of pain, function and general health, as well as hospital resource and medication needs in patients undergoing primary total hip arthroplasty (THA); and second, to evaluate whether outcome differences are related to existing baseline differences in health and disease severity.

Methods

We included all primary THAs from a public hospital-based prospective arthroplasty registry, performed in a high-income country 2010 to 2017. Education was classified in three levels: ≤8years of schooling (low), 9-12years (medium), and ≥13years (high). Pain and function prior to and one-year after surgery were assessed with the Western Ontario McMaster Universities score (WOMAC) and general health with the 12-item short-form health survey (SF-12).

Results

Overall 963 patients were included, 340 (35.3%) with low, 306 (31.8%) with medium, and 317 (32.9%) with high education. With increasing educational level preoperative scores for pain, function and SF-12 mental health component increased. One year after surgery improvement was observed in all education categories for WOMAC pain and function, SF-12 mental and physical component. However, absolute postoperative scores remained lower in all four domains for the low education group. After adjustment for baseline characteristics differences were much attenuated and no longer significant. There was also greater resource need in low educated patients.

Conclusions

The inferior absolute results one year after surgery in less educated patients were largely due to older age, worse preoperative health and greater symptom severity calling for greater attention to timely and equal management, for more targeted perioperative care and increased support for the lower education group.

Pre-Operative Predictors for Discharge to Post-Acute Care Facilities After Total Knee Arthroplasty

BACKGROUND

Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA).

METHODS

We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers).

RESULTS

Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs.

CONCLUSION

This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

Impact of Neuraxial Versus General Anesthesia on Discharge Destination in Patients Undergoing Primary Total Hip and Total Knee Replacement

BACKGROUND

Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system.

METHODS

This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR.

RESULTS

Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52-1.76; P < .01) and (OR = 1.58, 95% CI, 1.49-1.67; P < .01), respectively.

CONCLUSIONS

Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.

Comparing Outcomes for Female Total Knee Arthroplasty Patients Under Global Budget Revenue

Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014-2016). The female proportion decreased (-1.9%; P=.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P<.001). The mean length of stay (LOS), charges, and costs were decreased after GBR implementation (all P<.001). More patients were discharged routine and had fewer readmissions (both P<.001). There were fewer complications, including deep venous thromboses/pulmonary emboli, urinary tract infections, and blood transfusions (all P<.001). The difference-in-difference analyses suggested more females were discharged with home health care and had longer LOS than did males (both P<.001). The GBR appears to meet its main objective of cost reduction and improvements in quality of care. However, the proportion of females receiving TKA decreased, and their LOS did not improve as much as that of males. As other states consider global budgets, more research is needed to ensure this all-payer, rate-setting, capitated system does not cause decreased access to care. [Orthopedics. 2021;44(2):e266-e273.].

Comorbidity Burden Contributing to Racial Disparities in Outpatient Versus Inpatient Total Knee Arthroplasty

INTRODUCTION

Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes.

RESULTS

A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery.

DISCUSSION

Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.

Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures

AIMS

The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF).

PATIENTS AND METHODS

All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications.

RESULTS

A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9-67.5% vs. 51.1%; 95% CI 50.3-51.9%; p < 0.001) and major adverse events (75.5%; 95% CI 73.8-77.1% vs. 61.7%; 95% CI 60.9-62.5%; p < 0.001). With regard to surgical complications, after adjustment of patient risk profiles, there were no differences between females and males after LPF (p > 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56-2.22; p < 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46-2.12; p < 0.001) compared to women.

CONCLUSION

The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement

Importance

The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care.

Objective

To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures.

Design, Setting, and Participants

This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020.

Exposures

Implementation of the CJR model in 2016.

Main Outcomes and Measures

Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends.

Results

The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups.

Conclusions and Relevance

Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Community Deprivation Index and Discharge Destination After Elective Hip Replacement

OBJECTIVE

To examine how the deprivation level of the community in which one lives influences discharge disposition and the odds of 90-day readmission after elective total hip arthroplasty (THA).

METHODS

We performed a retrospective cohort study on 84,931 patients who underwent elective THA in the Pennsylvania Health Care Cost Containment Council database from 2012 to 2016. We used adjusted binary logistic regression models to test the association between community Area Deprivation Index (ADI) level and patient discharge destination as well as 90-day readmission. We included an interaction term for community ADI level and patient race in our models to assess the simultaneous effect of both on the outcomes.

RESULTS

After adjusting for patient- and facility-level characteristics, we found that patients from high ADI level communities (most disadvantaged), compared to patients from low ADI level communities (least disadvantaged), were more likely to be discharged to an institution as opposed to home for postoperative care and rehabilitation (age <65 years adjusted odds ratio [OR_adj ] 1.47; age ≥65 years OR_adj 1.31; both P < 0.001). The interaction effect of patient race and ADI level on discharge destination was statistically significant in those patients age ≥65 years, but not in patients age <65 years. The association with ADI level on 90-day readmission was not statistically significant.

CONCLUSION

In this statewide sample of patients who underwent elective THA, the level of deprivation of the community in which patients reside influences their discharge disposition, but not their odds of 90-day readmission to an acute-care facility.

A Preoperative Risk Prediction Tool for Discharge to a Skilled Nursing or Rehabilitation Facility After Total Joint Arthroplasty

BACKGROUND

Discharge to rehabilitation or a skilled nursing facility (SNF) after total joint arthroplasty remains a primary driver of cost excess for bundled payments. An accurate preoperative risk prediction tool would help providers and health systems identify and modulate perioperative care for higher risk individuals and serve as a vital tool in preoperative clinic as part of shared decision-making regarding the risks/benefits of surgery.

METHODS

A total of 10,155 primary total knee (5,570, 55%) and hip (4,585, 45%) arthroplasties performed between June 2013 and January 2018 at a single institution were reviewed. The predictive ability of 45 variables for discharge location (SNF/rehab vs home) was tested, including preoperative sociodemographic factors, intraoperative metrics, postoperative labs, as well as 30 Elixhauser comorbidities. Parameters surviving selection were included in a multivariable logistic regression model, which was calibrated using 20,000 bootstrapped samples.

RESULTS

A total of 1786 (17.6%) cases were discharged to a SNF/rehab, and a multivariable logistic regression model demonstrated excellent predictive accuracy (area under the receiver operator characteristic curve: 0.824) despite requiring only 9 preoperative variables: age, partner status, the American Society of Anesthesiologists score, body mass index, gender, neurologic disease, electrolyte disorder, paralysis, and pulmonary circulation disorder. Notably, this model was independent of surgery (knee vs hip). Internal validation showed no loss of accuracy (area under the receiver operator characteristic curve: 0.8216, mean squared error: 0.0004) after bias correction for overfitting, and the model was incorporated into a readily available, online prediction tool for easy clinical use.

CONCLUSION

This convenient, interactive tool for estimating likelihood of discharge to a SNF/rehab achieves excellent accuracy using exclusively preoperative factors. These should form the basis for improved reimbursement legislation adjusting for patient risk, ensuring no disparities in access arise for vulnerable populations.

LEVEL OF EVIDENCE

III.

Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?

BACKGROUND

Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities.

METHODS

A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course.

RESULTS

Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively.

DISCUSSION

This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty

BACKGROUND

Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program.

METHODS

A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status.

RESULTS

In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m², P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent.

CONCLUSION

OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

Sex- and Gender-specific Analysis in Orthopaedic Studies

BACKGROUND

Orthopaedic studies have reported the prevalence of injuries and outcomes after treatment in men and women patients, and although these differences have been recognized, few studies have evaluated for gender-specific injury patterns, disease progression, and treatment outcomes. A thorough understanding of gender-related differences is important to better individualize treatment and improve outcomes.

QUESTIONS/PURPOSES

In this study, we sought (1) to determine the proportion of studies published in six orthopaedic journals that provided sex- or gender-specific analyses in 2016 and whether a difference was found in outcomes between men and women and (2) to evaluate whether this proportion varied across several orthopaedic subspecialty journals or between general orthopaedic journals and subspecialty journals.

METHODS

Six leading orthopaedic surgery journals were selected for review, including two general orthopaedic journals (Journal of Bone and Joint Surgery and Clinical Orthopaedics and Related Research®) and four subspecialty journals (American Journal of Sports Medicine, Journal of Arthroplasty, Journal of Shoulder and Elbow Surgery, and Spine). Journal issues published in the even-numbered months of 2016 were reviewed for clinical randomized controlled, cohort, and case-control studies in which women were a part of the study population. A total of 712 studies evaluating 24,607,597 patients met the criteria and were included in our review of publications from 2016. The selected studies were stratified based on whether gender was a variable in a multifactorial statistical model. Outcomes of interest included the proportion of patients who were women and the presence or absence of a gender-specific analysis. These endpoints were compared between journals.

RESULTS

Overall, 55% (13,565,773 of 24,607,597) of patients analyzed in these studies were women. Only 34% (241 of 712) of the studies published in 2016 included gender as variable in a multifactorial statistical model. Of these, 39% (93 of 241) demonstrated a difference in the outcomes between patients who were men and women. The Journal of Arthroplasty had the greatest percentage of patients who were women (60%, 9,251,068 of 15,557,187) and the American Journal of Sports Medicine had the lowest (44%, 1,027,857 of 2,357,139; p < 0.001). Orthopaedic subspecialty journals tended to include a greater percentage of women (54%) than did general orthopaedic journals (50%; p = 0.04).

CONCLUSION

Currently, it is unclear what percentage of published orthopaedic studies should include a gender-specific analysis. In the current study, more than one-third of publications that performed a gender-specific analysis demonstrated a difference in outcomes between men and women, thereby emphasizing the need to determine when such an analysis is warranted.

CLINICAL RELEVANCE

Future studies should aim to determine when a gender-specific analysis is necessary to improve the management of orthopaedic injuries in men and women. It is important for investigators at the individual-study level to look for every opportunity to ensure that both men's and women's health needs are met by performing appropriate by-sex and by-gender analyses, but not to perform them when they are unnecessary or inappropriate.

Development and Validation of a Model for Predicting Rehabilitation Care Location Among Patients Discharged Home After Total Knee Arthroplasty

BACKGROUND

Demand for joint replacement is increasing, with many patients receiving postsurgical physical therapy (PT) in non-inpatient settings. Clinicians need a reliable tool to guide decisions about the appropriate PT setting for patients discharged home after surgery. We developed and validated a model to predict PT location for patients in our health system discharged home after total knee arthroplasty.

METHODS

We analyzed data for patients who completed a preoperative total knee risk assessment in 2017 (model development cohort) or during the first 6 months of 2018 (model validation cohort). The initial total knee risk assessment, to guide rehabilitation disposition, included 28 variables in mobility, social, and environment domains, and on patient demographics and comorbidities. Multivariable logistic regression was used to identify factors that best predict discharge to home health service (HHS) vs home with outpatient PT. Model performance was assessed by standard criteria.

RESULTS

The development cohort included 259 patients (19%) discharged to HHS and 1129 patients (81%) discharged to home with outpatient PT. The validation cohort included 609 patients, with 91 (15%) discharged to HHS. The final model included age, gender, motivation for outpatient PT, and reliable transportation. Patients without motivation for outpatient PT had the highest probability of discharge to HHS, followed by those without reliable transportation. Model performance was excellent in the development and validation cohort, with c-statistics of 0.91 and 0.86, respectively.

CONCLUSION

We developed and validated a predictive model for total knee arthroplasty PT discharge location. This model includes 4 variables with accurate prediction to guide patient-clinician preoperative decision making.

A Risk Assessment Tool Based on Orthopedic Psychosocial and Health Status Factors is Associated With Post-Acute Resources

BACKGROUND

We implemented a risk assessment tool (RAT) used by clinical navigators to quantify pre-operative mobility, home safety, social/cognitive barriers, and patient health history. We sought to determine if this RAT is associated with the need for post-acute care (PAC) services defined as inpatient rehabilitation and skilled nursing facility, home health, and none (home) following total joint arthroplasty.

METHODS

The study sample comprised of a total of 1438 primary TJA patients included in a bundled payment model. The RAT score, which ranges from 0 to 100, with higher scores representing healthier, more independent patents, was the key independent variable and post-acute service was the primary outcome variable.

RESULTS

The median RAT score was 83 (interquartile range 78-87.5) for no PAC discharges compared to 74 (interquartile range 67-81) for inpatient PAC discharges (P < .0001). After adjusting for the effects of length of hospital stay, surgery type, and patient gender, there was 6× increased odds of inpatient PAC for higher risk patients compared to low risk patients. A RAT score of 74 predicts discharges without PAC 87% of the time.

CONCLUSION

The RAT that is based on psychosocial, cognitive, environmental factors, and health status was significantly associated with the need for PAC services. The next step is to build and validate a real time, risk adjustment model to assist physicians and patients with planning post-discharge resources.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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