Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty

Socioeconomic deprivation is associated with worse health-related quality of life and greater opioid analgesia use while waiting for hip and knee arthroplasty

Aims

The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses.

Results

Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative "worse than death" EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005).

Conclusion

More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available.

Understanding the Influence of Single Payer Health Insurance on Socioeconomic Disparities in Total Hip Arthroplasty (THA) Utilization: A Transnational Analysis

OBJECTIVE

Access to care varies between countries. It is theorized that income-based disparities in access may be reduced in countries with universal health insurance relative to the United States, but data are currently limited. We hypothesized that income-based differences in total hip arthroplasty (THA) utilization and outcomes would be larger in the United States than in Canada.

METHODS

We retrospectively compared all patients undergoing THA from 2012 to 2018 in Pennsylvania, the United States, and Ontario, Canada. We compared age-standardized and sex-standardized per-capita THA utilization in the United States and Canada overall and across different income strata, where income strata were defined by neighborhood income quintile. We also examined income-based differences in rates of 1-year revision, 90-day mortality, and 90-day readmission.

RESULTS

Overall THA utilization per 10,000 people per year was higher across all income groups in Pennsylvania compared with Ontario (15.1 versus 8.8, P < 0.001 in lowest-income quintile; 21.4 versus 12.6, P < 0.001 in highest-income quintile). Income-based differences in utilization in the highest-income vs lowest-income quintile groups were greater in Ontario (43.2%) than Pennsylvania (41.7%). The adjusted odds for the lowest-income group compared with the highest-income group of 1-year revision were greater in Ontario compared with Pennsylvania (P = 0.03), and risk of 90-day mortality and 90-day readmission was similar between the regions.

CONCLUSION

Income-based differences in THA utilization were more notable in Ontario than in Pennsylvania. In addition, patients in low-income communities in Ontario were at equal or greater risk relative to high-income community patients for adverse outcomes compared with patients in Pennsylvania. Income-based disparities in THA utilization and outcomes were smaller in the United States than in Canada, in contrast to what might be expected.

LEVEL OF EVIDENCE

III.

Medicaid Insurance is Associated With Decreased MRI Use for Ankle Sprains Compared With Private Insurance: A Retrospective Database Analysis

BACKGROUND

Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains.

QUESTIONS/PURPOSES

Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery?

METHODS

Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI.

RESULTS

After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001).

CONCLUSION

Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use.

LEVEL OF EVIDENCE

Level III, prognostic study.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases

BACKGROUND

Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

METHODS

Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant.

RESULTS

Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

CONCLUSIONS

There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population

BACKGROUND

Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations.

METHODS

Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression.

RESULTS

Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients.

CONCLUSION

Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA.

LEVEL OF EVIDENCE

III.

Income and Insurance Status Impact Access to Health Care for Hip Osteoarthritis

Purpose

To explore differences in the affordability of and accessibility to health care among adults with hip osteoarthritis with respect to race/ethnicity, income, and insurance status.

Methods

This cross-sectional retrospective study was conducted using 2016 National Health Interview Survey (NHIS) data. NHIS data collection occurred continuously from January to December 2016. Individuals belonging to households and noninstitutionalized groups were included in the study. Because NHIS randomized surveys are conducted face-to-face on an annual basis, follow-up data are not collected.

Results

Answers from 38,158,634 weighted respondents with a mean age of 58.33 ± 0.33 years were assessed. Among adults with hip osteoarthritis, those with public insurance had increased odds of delaying care owing to lack of transportation and had decreased odds of delaying care and follow-up care owing to cost. Individuals who were uninsured or who belonged to lower income brackets were associated with increased odds of being unable to afford or utilize health care.

Conclusions

In this study, we found that income bracket and insurance status affect the accessibility to health care among adults with hip osteoarthritis in the United States.

Level of Evidence

Level IV, prognostic case series.

An Interpretable Machine Learning Model for Predicting 10-Year Total Hip Arthroplasty Risk

BACKGROUND

As the demand for total hip arthroplasty (THA) rises, a predictive model for THA risk may aid patients and clinicians in augmenting shared decision-making. We aimed to develop and validate a model predicting THA within 10 years in patients using demographic, clinical, and deep learning (DL)-automated radiographic measurements.

METHODS

Patients enrolled in the Osteoarthritis Initiative were included. DL algorithms measuring osteoarthritis- and dysplasia-relevant parameters on baseline pelvis radiographs were developed. Demographic, clinical, and radiographic measurement variables were then used to train generalized additive models to predict THA within 10 years from baseline. A total of 4,796 patients were included (9,592 hips; 58% female; 230 THAs (2.4%)). Model performance using 1) baseline demographic and clinical variables 2) radiographic variables, and 3) all variables were compared.

RESULTS

Using 110 demographic and clinical variables, the model had a baseline area under the receiver operating curve (AUROC) of 0.68 and area under the precision recall curve (AUPRC) of 0.08. Using 26 DL-automated hip measurements, the AUROC was 0.77 and AUPRC was 0.22. Combining all variables, the model improved to an AUROC of 0.81 and AUPRC of 0.28. Three of the top five predictive features in the combined model were radiographic variables including minimum joint space along with hip pain and analgesic use. Partial dependency plots revealed predictive discontinuities for radiographic measurements consistent with literature thresholds of osteoarthritis progression and hip dysplasia.

CONCLUSION

A machine learning model predicting 10-year THA performed more accurately with DL radiographic measurements. The model weighted predictive variables in concordance with clinical THA-pathology assessments.

Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

BACKGROUND

To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity.

QUESTIONS/PURPOSES

We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?

METHODS

A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively.

RESULTS

Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles.

CONCLUSION

These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty

BACKGROUND

Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA.

RESULTS

Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA.

CONCLUSION

TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.

Race Is Associated With Risk of Salvage Procedures and Postoperative Complications After Hip Procedures in Children With Cerebral Palsy

BACKGROUND

Despite the many surgical interventions available for spastic hip dysplasia in children with cerebral palsy, a radical salvage hip procedure may still ultimately be required. The purpose of this study was to assess whether race is an independent risk factor for patients with cerebral palsy to undergo a salvage hip procedure or experience postoperative complications for hip dysplasia treatment.

METHODS

This is a retrospective cohort analysis utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database from 2012 to 2019. International Classification of Diseases, 9th and 10th Revisions, Clinical Modifications (ICD-9-CM, ICD-10-CM), and current procedural terminology (CPT) codes were used to identify patients with cerebral palsy undergoing hip procedures for hip dysplasia and to stratify patients into salvage or reconstructive surgeries.

RESULTS

There was a total of 3906 patients with cerebral palsy between the ages of 2 and 18 years undergoing a procedure for hip dysplasia, including 1995 (51.1%) White patients, 768 (19.7%) Black patients, and 1143 (29.3%) patients from other races. Both Black ( P =0.044) and White ( P =0.046) races were significantly associated with undergoing a salvage versus a reconstructive hip procedure, with Black patients having an increased risk compared to White patients [adjusted odds ratio (OR) 1.77, confidence interval (CI) 1.02-3.07]. Only Black patients were found to have an increased risk of any postoperative complication compared to White patients, with an adjusted OR of 1.26 (CI 1.02-1.56; P =0.033). Both White ( P =0.017) and black ( P =0.004) races were found to be significantly associated with medical complications, with Black patients having an increased risk (adjusted OR 1.43, CI 1.12-1.84) compared to White patients. There were no significant findings between the race and risk of surgical site complications, unplanned readmissions, or reoperations.

CONCLUSION

This study demonstrates that patient race is an independent association for the risk of pediatric patients with cerebral palsy to both undergo a salvage hip procedure and to experience postoperative medical complications, with Black patients having an increased risk compared to White.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Lower Rates of Ceramic Femoral Head Use in Non-White Patients in the United States, a National Registry Study

BACKGROUND

The purpose of our study was to investigate the association of race and ethnicity with the use of the newest technology and postoperative outcomes in total hip arthroplasty (THA) using the American Academy of Orthopaedic Surgeons (AAOS) American Joint Replacement Registry (AJRR).

METHODS

Adult THA procedures were queried from the AJRR from 2012 to 2020. A mixed-effects multivariate regression model was used to evaluate the association of race and ethnicity with the use of the newest technology (ceramic femoral head, dual-mobility implant, and robotic assist) at 30-day, and 90-day readmission. A proportional subdistribution hazard model was used to model a risk of revision THA.

RESULTS

There were 85,188 THAs with complete data for an analysis of outcomes and 103,218 for an analysis of ceramic head usage. The median length of follow-up was 37.9 months (interquartile range [IQR] 21.6 to 56.3 months). In multivariate models, compared to White non-Hispanic patients, Black (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.92, P < .001), Hispanic (OR 0.76, CI 0.59-0.99, P = .037), Asian (OR 0.74, CI 0.55-1.00, P = .045), and Native American (OR 0.52, CI 0.30-0.87, P = .004) patients all had significantly lower rates of ceramic head use in THA. Compared to White non-Hispanic patients, Asian (hazard ratio [HR] 0.39, CI 0.18-0.86, P = .008) and Hispanic (HR 0.43, CI 0.19-0.98, P = .043) patients had significantly lower rates of revision. No differences in 30-day or 90-day readmission rates were seen.

CONCLUSION

Black, Hispanic, Native American, and Asian patients had lower rates of ceramic head use in THA when compared to White patients. These differences did not translate into worse clinical outcomes on a short-term follow-up. In fact, Asian patients had lower revision rates compared to non-Hispanic White patients. Additional study is necessary to evaluate the long-term consequence of lower ceramic head use in non-White patients in the United States.

Racial and Ethnic Disparities in the Imaging Workup and Treatment of Knee and Hip Osteoarthritis

BACKGROUND

There is limited evidence on sociodemographic differences in osteoarthritis management, particularly in non-African American (AA) minorities. We sought to identify differences in imaging modalities, administration of intra-articular injections, and total joint arthroplasty (TJA) between racial/ethnic groups.

METHODS

We retrospectively reviewed patients presenting to outpatient clinics with a diagnosis of hip or knee osteoarthritis from January 2013 to March 2020 at a tertiary center. Univariate analyses compared differences between groups. Multivariate logistic regression analyses determined sociodemographic predictors of imaging workup and treatment.

RESULTS

In total, 105,873 patients were included. There were 74,769 (70.6%) Caucasian, 27,117 (25.6%) AA, 1,878 (1.8%) Hispanic, 1,479 (1.4%) Asian, and 630 (0.6%) Native American patients. Multivariate analyses demonstrated that AAs had decreased odds of undergoing a knee magnetic resonance imaging (odds ratio [OR] 0.77, P < .001) or injection (OR 0.94, P = .006). Asian patients had lower odds of receiving any hip X-ray (OR 0.72, P = .047) or knee injection (OR 0.83, P = .017). AA (total knee arthroplasty [TKA]: OR 0.51, P < .001; total hip arthroplasty [THA]: OR 0.57, P < .001), Hispanic (TKA: OR 0.69, P = .003; THA: OR 0.60, P = .006), and Asian (TKA: OR 0.73, P = .010; THA: OR 0.56, P = .010) patients had lower odds of undergoing TJA compared to Caucasians. We found that higher income quartiles had greater odds of receiving a magnetic resonance imaging and TJA, males had lower odds of receiving injections and greater odds of undergoing TJA, and Medicaid and self-pay patients had lower odds of undergoing TJA (P < .05).

CONCLUSION

After adjusting for sociodemographic factors, we found disparities in the imaging, administration of injections, and/or arthroplasty for AA, Asian, and Hispanic patients. Insurance status, income, and gender were also associated with imaging and treatments performed in managing hip and knee osteoarthritis.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability

Purpose

To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors.

Methods

Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type.

Results

In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery.

Conclusions

Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation.

Clinical Relevance

Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.