Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty

Influence of Demographic and Socioeconomic Factors on Hospital Distance for Total Knee Arthroplasty

Background

Disparities exist in access to and outcomes following total knee arthroplasty. However, there is a paucity of data examining the relationship between travel distance and these disparities.

Methods

We used the Healthcare Cost and Utilization Project, American Hospital Association, and UnitedStatesZipCodes.org Enterprise databases to gather patient demographic and postoperative outcomes data. We calculated the distance traveled between patient population-weighted zip code centroid points and the hospitals at which they received total knee arthroplasty. We then examined the association between travel distance and patient demographic characteristics as well as postoperative adverse outcomes.

Results

Among of cohort of 384,038 patients, white patients (16.58 miles) traveled farther on average than Black (10.05) or Hispanic patients (10.54) (P < .0001). Medicare and commercial insurance coverage were associated with greater travel distance (P < .0001). Fewer medical comorbidities (P < .001) and residence in the highest-income areas (P < .0001) were associated with increased travel distance. Differences in postoperative complication rates related to travel distance were not clinically significant.

Conclusions

Increased travel distance for total knee arthroplasty was associated with white race, commercial and Medicare insurance coverage, fewer medical comorbidities, and increased socioeconomic status. Future work is needed to determine the underlying causal mechanisms leading to these differences in access to specialized care.

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.

Neighborhood Socioeconomic Disadvantage Associated With Increased Healthcare Utilization After Total Hip Arthroplasty

BACKGROUND

The multifaceted effects of socioeconomic status on healthcare outcomes can be difficult to quantify. The Area Deprivation Index (ADI) quantifies a socioeconomic disadvantage with higher scores indicating more disadvantaged groups. The present study aimed to describe the ADI distribution for primary total hip arthroplasty (THA) patients stratified by patient demographics and to characterize the association of ADI with healthcare utilization (discharge disposition and length of stay [LOS]), 90-day emergency department (ED) visits, and 90-day all cause readmissions.

METHODS

Two thousand three hundred and ninety one patients who underwent primary elective THA over a 13-month period were included. A multivariable binary logistic regression analysis with outcomes of nonhome discharge, prolonged LOS (>3 days), 90-day ED visits, and 90-day readmission were performed using predictors of ADI, gender, race, smoking status, body mass index, insurance status, and Charlson comorbidity index. Plots of restricted cubic splines were used to graph associations between ADI as a continuous variable and the outcomes of interest using odds ratios.

RESULTS

In the multivariable regression model, there were statistically significant higher odds of nonhome discharge (OR, 1.82; 95% CI, 1.19-2.77, P = .005) for individuals in the 61-80 ADI quintile as compared to the reference group of 21-40. Individuals in the highest ADI quintile, 81-100, had the greatest odds of nonhome discharge (OR, 2.20; 95% CI, 1.39-3.49, P < .001) and prolonged LOS (OR, 1.91, 95% CI, 1.28-2.84, P = .001).

CONCLUSIONS

Higher ADI is associated with an increased healthcare utilization within 90 days of THA.

Demographics of Patients Traveling Notable Distances to Receive Total Knee Arthroplasty

Although disparities exist in patient access to and outcomes after total knee arthroplasty (TKA), there are limited data regarding the relationship between travel distance and patient demographics or postoperative complications.

Nationwide Estimates of Gender-Affirming Chest Reconstruction in the United States, 2016-2019

BACKGROUND

Section 1557 of the Affordable Care Act, introduced in 2016, increased access to gender-affirming surgeries for transgender and gender diverse individuals. Masculinizing chest reconstruction (e.g., mastectomy) and feminizing chest reconstruction (e.g., augmentation mammaplasty), often outpatient procedures, are the most frequently performed gender-affirming surgeries. However, there is a paucity of information about the demographics of patients who undergo gender-affirming chest reconstruction.

OBJECTIVES

The authors sought to investigate the incidence, demographics, and spending for ambulatory gender-affirming chest reconstruction utilizing nationally representative data from 2016 to 2019.

METHODS

Employing the Nationwide Ambulatory Surgery Sample, the authors identified patients with an International Classification of Diseases diagnosis code of gender dysphoria who underwent chest reconstruction between 2016 and 2019. Demographic and clinical characteristics were recorded for each encounter.

RESULTS

A weighted estimate of 21,293 encounters for chest reconstruction were included (17,480 [82.1%] masculinizing and 3813 [27.9%] feminizing). Between 2016 and 2019, the number of chest surgeries per 100,000 encounters increased by 143.2% from 27.3 to 66.4 (P < 0.001). A total 12,751 (59.9%) chest surgeries were covered by private health insurance, 6557 (30.8%) were covered by public health insurance, 1172 (5.5%) were self-pay, and 813 (3.8%) had other means of payment. The median total charges were $29,887 (IQR, $21,778-$43,785) for chest reconstruction overall. Age, expected primary payer, patient location, and median income varied significantly by race (P < 0.001).

CONCLUSIONS

Gender-affirming chest reconstructions are on the rise, and surgeons must understand the background and needs of transgender and gender diverse patients who require and choose to undergo surgical transitions.

LEVEL OF EVIDENCE: 3

Racial and Socioeconomic Differences in Distance Traveled for Elective Hip Arthroplasty

Introduction:

There are data that disparities exist in access to total hip arthroplasty (THA). However, to date, no study has examined the relationship between distance traveled to undergo THA and patient demographic characteristics, such as race, insurance provider, and income level as well as postoperative outcomes.

Methods:

Data from the Healthcare Cost and Utilization Project, American Hospital Association, and the United States Postal Service were used to calculate the geographic distance between 211,806 patients' population-weighted zip code centroid points to the coordinates of the hospitals at which they underwent THA. We then used Healthcare Cost and Utilization Project data to examine the relationships between travel distance and both patient demographic indicators and postoperative outcomes after THA.

Results:

White patients traveled farther on average to undergo THA as compared with their non-White counterparts (17.38 vs 13.05 miles) (P < 0.0001). Patients with commercial insurance (17.19 miles) and Medicare (16.65 miles) traveled farther on average to receive care than did patients with Medicaid insurance coverage (14.00 miles) (P = 0.0001). Patients residing in zip codes in the top income quartile traveled farther to receive care (18.73 miles) as compared with those in the lowest income quartile (15.31 miles) (P < 0.0001). No clinically significant association was found between travel distance and adverse postoperative outcomes after THA.

Discussion:

Race, insurance provider, and zip code income quartile are associated with differences in the distance traveled to undergo THA. These findings may be indicative of underlying disparities in access to care across patient populations.