Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization

Lai E, Bradford L, Bass AR, Amen TB, Russell LA, Mehta B, Parks M, Figgie M, Goodman S. Racial Differences in Patient Satisfaction With the Hospital Experience Undergoing Primary Unilateral Hip and Knee Arthroplasty: A Retrospective Study

Background

Press Ganey (PG) inpatient survey is widely used to track patient satisfaction with the hospital experience. Our aim was to use the PG survey to determine if there are racial differences in overall hospital experience and perception of nurses and surgeons following hip and knee arthroplasty.

Methods

We retrospectively analyzed Black and White patients from hip and knee arthroplasty registries from a single institution between July 2010 and February 2012. The overall assessment score for the hospital experience and perception of the nurse and surgeon questions from the PG inpatient survey were dichotomized as "not completely satisfied" or "completely satisfied". Multivariable logistic regression models were developed to determine the impact of race on the likelihood of being 'completely satisfied' in the hip and knee cohorts.

Results

There were 2517 hip and 2114 knee patients who underwent surgery and completed the PG survey, of whom 3.9% were Black and 96.0% were White. Black patients were less likely to be completely satisfied with their hospital experience compared to White patients in the hip (odds ratio 0.62, confidence interval 0.39-1.00, P = .049) and knee (odds ratio 0.52, confidence interval 0.33-0.82, P = .005) cohorts. Black patients were also less likely to be completely satisfied with multiple aspects of care they received from the nurse and surgeon in both cohorts.

Conclusions

We found that the PG Survey shows Black patients were less likely to be completely satisfied than White patients with the hospital experience, including their interactions with nurses and surgeons. More work is needed to understand this difference.

Regional Implicit Racial Bias and Rates of Breast Reconstruction, Complications, and Cost Among US Patients With Breast Cancer

Importance

Racial disparities influencing breast reconstruction have been well-researched; however, the role of implicit racial bias remains unknown. An analysis of the disparities in care for patients with breast cancer may serve as a policy target to increase the access and quality of care for underserved populations.

Objective

To identify whether variations in implicit racial bias by region are associated with the differences in rates of immediate breast reconstruction, complications, and cost for White patients and patients from minoritized racial and ethnic groups.

Design, Setting, and Participants

This cohort study used data from the National Inpatient Sample (NIS) from 2009 to 2019. Adult female patients with a diagnosis of or genetic predisposition for breast cancer receiving immediate breast reconstruction at the time of mastectomy were included. Patients receiving both autologous free flap and implant-based reconstruction were included in this analysis. US Census Bureau data were extracted to compare rates of reconstruction proportionately. The Implicit Association Test (IAT) was used to classify whether implicit bias was associated with the primary outcome variables. Data were analyzed from April to November 2022.

Exposure

IAT score by US Census Bureau geographic region.

Main Outcomes and Measures

Variables of interest included demographic data, rate of reconstruction, complications (reconstruction-specific and systemic), inpatient cost, and IAT score by region. Spearman correlation was used to determine associations between implicit racial bias and the reconstruction utilization rate for White patients and patients from minoritized racial and ethnic groups. Two-sample t tests were used to analyze differences in utilization, complications, and cost between the 2 groups.

Results

A total of 52 115 patients were included in our sample: 38 487 were identified as White (mean [SD] age, 52.0 [0.7] years) and 13 628 were identified as minoritized race and ethnicity (American Indian, Asian, Black, and Hispanic patients and patients with another race or ethnicity; mean [SD] age, 49.7 [10.5] years). Implicit bias was not associated with disparities in breast reconstruction rates, complications, or cost. Nonetheless, the White-to-minoritized race and ethnicity utilization ratio differed among the regions studied. Specifically, the reconstruction ratio for White patients to patients with minoritized race and ethnicity was highest for the East South Central Division, which includes Alabama, Kentucky, Mississippi, and Tennessee (2.17), and lowest for the West South Central Division, which includes Arkansas, Louisiana, Oklahoma, and Texas (0.75).

Conclusions and Relevance

In this cohort study of patients with breast cancer, regional variation of implicit bias was not associated with differences in breast reconstruction utilization, complications, or cost. Regional disparities in utilization among racial and ethnic groups suggest that collaboration from individual institutions and national organizations is needed to develop robust data collection systems. Such systems could provide surgeons with a comparative view of their care. Additionally, collaboration with high-volume breast centers may help patients in low-resource settings receive the desired reconstruction for their breast cancer care, helping improve the utilization rate and quality of care.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty

BACKGROUND

Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA.

METHODS

We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores.

RESULTS

Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS.

CONCLUSION

Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.