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Ward BA, Kowalsky MS. Treatment of race and ethnicity in shoulder and elbow research: An analysis of the most cited papers on rotator cuff repair. J Orthop 2024; 55:86-90. [PMID: 38665989 PMCID: PMC11039319 DOI: 10.1016/j.jor.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Background This study examined the current approach to the inclusion of race and ethnicity among frequently referenced shoulder surgery literature and discussed guidance for best practices for the inclusion of race and ethnicity in shoulder research. Methods The shoulder literature were systematically reviewed for the most frequently cited studies discussing rotator cuff repair, total shoulder arthroplasty, and Bankart repair. All reviewed studies met the timeline criteria (2013-2022). Only studies with clinical outcomes were included. Review articles, meta-analyses, systematic reviews, basic science studies, or any manuscript that did not represent clinical outcomes research were excluded. Author, year issued, the journal in which the paper was published, study design, the number of subjects, duration of follow-up, independent variables, dependent variables, results, and conclusions were extracted from the articles that met the inclusion criteria. Whether race and/or ethnicity were included in the study design in any way was also recorded. For those studies in which race and ethnicity were included, a detailed analysis of the paper's treatment of race using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals was performed and recorded. Results In the "rotator cuff repair" cohort of papers, there were 2 articles that mention race. Out of the 2 articles that mentioned race, neither included race appropriately using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals. In the "Bankart repair" cohort of papers, each article lacked the mention of race among their patient population. The "total shoulder arthroplasty" manuscripts also did not include treatment of race and ethnicity in any way. Discussion Race and ethnicity and other social determinants of health can be used to understand the source of healthcare disparities. Unless a thoughtful and deliberate consideration of race and ethnicity is undertaken, their inclusion in clinical research can be a double-edged sword due to the potential race and ethnicity-centered treatment involvement can be rooted in fallacies. In shoulder surgery clinical research, race and ethnicity should be considered in concert with social factors that could exacerbate poor patient outcomes in our patient population. Level of evidence Level V.
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Affiliation(s)
| | - Marc S. Kowalsky
- ONS Foundation for Clinical Research & Education, Orthopedic & Neurosurgery Specialists, 40 Valley Drive 6, Greenwich Office Park, Greenwich, CT, 06831, USA
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Ong CB, Buchan GBJ, Hecht CJ, Liu D, Petterwood J, Kamath AF. Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system resulted in greater improvements in hip-specific outcome measures at one-year compared to a CT-based robotic-assisted system. Int J Med Robot 2024; 20:e2650. [PMID: 38856120 DOI: 10.1002/rcs.2650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The purpose of this study was to compare one-year patient reported outcome measures between a novel fluoroscopy-based robotic-assisted (FL-RTHA) system and an existing computerised tomography-based robotic assisted (CT-RTHA) system. METHODS A review of 85 consecutive FL-RTHA and 125 consecutive CT-RTHA was conducted. Outcomes included one-year post-operative Veterans RAND-12 (VR-12) Physical (PCS)/Mental (MCS), Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function (PS)/Joint replacement, and University of California Los Angeles (UCLA) Activity scores. RESULTS The FL-RTHA cohort had lower pre-operative VR-12 PCS, HOOS Pain, HOOS-PS, HOOS-JR, and UCLA Activity scores compared with patients in the CT-RTHA cohort. The FL-RTHA cohort reported greater improvements in HOOS-PS scores (-41.54 vs. -36.55; p = 0.028) than the CT-RTHA cohort. Both cohorts experienced similar rates of major post-operative complications, and had similar radiographic outcomes. CONCLUSIONS Use of the fluoroscopy-based robotic system resulted in greater improvements in HOOS-PS in one-year relative to the CT-based robotic technique.
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Affiliation(s)
- Christian B Ong
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Graham B J Buchan
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David Liu
- Gold Coast Centre for Bone and Joint Surgery, Palm Beach, Queensland, Australia
| | - Joshua Petterwood
- Department of Orthopaedics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Sobba W, Lawrence KW, Haider MA, Thomas J, Schwarzkopf R, Rozell JC. The influence of body mass index on patient-reported outcome measures following total hip arthroplasty: a retrospective study of 3,903 Cases. Arch Orthop Trauma Surg 2024; 144:2889-2898. [PMID: 38796819 DOI: 10.1007/s00402-024-05381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification. METHODS Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99 kg/m2), overweight (25-29.99 kg/m2), obese (30-39.99 kg/m2), and morbidly obese (> 40 kg/m2). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders. RESULTS We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR. CONCLUSIONS Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.
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Affiliation(s)
- Walter Sobba
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA
| | - Kyle W Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA
| | - Muhammad A Haider
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17 Street 15 Fl Suite 1518, New York, NY, USA.
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Singh V, Jayne CS, Cuero KJ, Thomas J, Rozell JC, Schwarzkopf R, Macaulay W, Davidovitch RI. Are We Moving in the Right Direction? Demographic and Outcome Trends in Same-day Total Hip Arthroplasty From 2015 to 2020. J Am Acad Orthop Surg 2024; 32:346-353. [PMID: 38194641 DOI: 10.5435/jaaos-d-23-00762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024] Open
Abstract
INTRODUCTION Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE III, Retrospective Review.
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Affiliation(s)
- Vivek Singh
- From the Department of Orthopedic Surgery, NYU Langone Health, New York, NY (Dr. Singh, Mr. Thomas, Dr. Rozell, Dr. Schwarzkopf, Dr. Macaulay, and Dr. Davidovitch), and the Department of Orthopaedic Surgery, Dignity Health St. Joseph's Medical Center, Stockton, CA (Dr. Singh, Dr. Jayne, and Dr. Cuero)
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Rana P, Brennan JC, Johnson AH, Turcotte JJ, Petre BM. Social Determinants of Health in Maryland Hip Arthroscopy Patients. Cureus 2024; 16:e52576. [PMID: 38371015 PMCID: PMC10874623 DOI: 10.7759/cureus.52576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Background Prior studies have demonstrated racial and socioeconomic disparities in patient-reported outcome measure (PROM) completion rates, and improvement exists across multiple orthopedic conditions. The purpose of this study was to assess whether these disparities are present in patients undergoing hip arthroscopy (HA) procedures. Methods A retrospective study of 306 patients undergoing HA from 2021 to 2023 was performed. Social determinants of health (SDOH) were compared between HA patients and the general Maryland population. Patients were then classified by whether they completed baseline and six-month PROMs (Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) instrument). Patients who completed PROMIS-PF were classified by whether or not they achieved minimal clinically important difference (MCID) at six months. Demographics and SDOH were compared using univariate analyses between patients who did and did not complete PROMs and between those who did and did not achieve MCID. SDOH were evaluated at the zip-code level using regional health information exchange measures. Results Compared to the Maryland population, HA patients resided in areas of lower social vulnerability. Preoperative and six-month PROMs were completed by 102 (33%) patients. No significant differences in demographics or any SDOH were found between patients who did and did not complete PROMs. Six-month MCID was achieved in 75 of 102 (74%) patients with complete PROMs; no significant differences in demographics or SDOH were observed between patients who did and did not achieve MCID. Conclusions For patients undergoing HA, disparities in patient-reported outcome completion rates and postoperative functional improvement do not appear to be present across demographics and SDOH, indicating equitable care is being delivered.
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Affiliation(s)
- Parimal Rana
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | - Jane C Brennan
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
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White PB, Forte SA, Bartlett LE, Osowa T, Bondy J, Aprigliano C, Danoff JR. A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital. J Arthroplasty 2023; 38:2549-2555. [PMID: 37276952 DOI: 10.1016/j.arth.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital. METHODS A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours. RESULTS We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%. CONCLUSION In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.
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Affiliation(s)
- Peter B White
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Salvador A Forte
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Lucas E Bartlett
- Department of Orthopaedic Surgery, Northwell Health at Huntington Hospital, Hunginton, New York
| | - Temisan Osowa
- Donald and Barbara Zucker School of Medicine/Hofstra, Hempstead, New York
| | - Jed Bondy
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Caroline Aprigliano
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
| | - Jonathan R Danoff
- Department of Orthopaedic Surgery, Northwell Health at North Shore University Hospital, Great Neck, New York
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Lawrence KW, Christensen TH, Bieganowski T, Buchalter DB, Meftah M, Lajam CM, Schwarzkopf R. The Impact of Surgeon Proficiency in Non-English-Speaking Patients' Primary Language on Outcomes After Total Joint Arthroplasty. Orthopedics 2023; 46:334-339. [PMID: 37276439 DOI: 10.3928/01477447-20230531-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].
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Dhanjani SA, Schmerler J, Wenzel A, Gomez G, Oni J, Hegde V. Racial and Socioeconomic Disparities in Risk and Reason for Revision in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:e815-e823. [PMID: 37276485 DOI: 10.5435/jaaos-d-22-01124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/11/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION Data regarding racial/ethnic and socioeconomic differences in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) have been inconsistent. This study examined racial/ethnic and socioeconomic disparities in comorbidity-adjusted risk and reason for rTHA and rTKA. METHODS Patients who underwent rTHA or rTKA between 2006 and 2014 in the National Inpatient Sample were identified. Multivariable logistic regression models adjusted for payer status, hospital geographic setting, and patient characteristics (age, sex, and Elixhauser Comorbidity Index) were used to examine the effect of race/ethnicity and socioeconomic status on trends in annual risk of rTHA/rTKA and causes of rTHA/rTKA. RESULTS Black patients were less likely to undergo rTHA and more likely to undergo rTKA while Hispanic patients were more likely to undergo rTHA and less likely to undergo rTKA ( P < 0.001 for all) compared with White patients. Patients residing in areas of lower income quartiles were more likely to undergo rTHA and rTKA compared with those in the highest quartile ( P < 0.001), and these disparities persisted and widened over time. Black, Hispanic, and Asian patients were less likely to undergo rTHA/rTKA because of dislocation compared with White patients ( P < 0.001 for all). Patients from areas of lower income quartiles were more likely to undergo rTHA because of septic complications and less likely to require both rTHA and rTKA because of mechanical complications ( P < 0.001 for all). DISCUSSION Racial/ethnic and socioeconomic disparities exist in risk and cause of rTHA and rTKA. Increasing awareness and a focus on minimizing variability in hospital quality may help mitigate these disparities.
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Affiliation(s)
- Suraj A Dhanjani
- From the Johns Hopkins University School of Medicine, Baltimore, MD (Dhanjani, Schmerler, and Gomez), and the Department of Orthopaedic Surgery, (Dr. Wenzel, Dr. Oni, Dr. Hegde), The Johns Hopkins University School of Medicine, Baltimore, MD (Wenzel, Oni, and Hegde)
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Thomas J, Bieganowski T, Carmody M, Macaulay W, Schwarzkopf R, Rozell JC. Patient Designation Prior to Total Knee Arthroplasty: How Can Preoperative Variables Impact Postoperative Status? J Arthroplasty 2023; 38:1658-1662. [PMID: 37590392 DOI: 10.1016/j.arth.2023.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively. METHODS We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion. RESULTS Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion. CONCLUSION Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.
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Affiliation(s)
- Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Mary Carmody
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - William Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Boakye LAT, Parker EB, Chiodo CP, Bluman EM, Martin EA, Smith JT. The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions. J Bone Joint Surg Am 2023; 105:1062-1071. [PMID: 36996237 DOI: 10.2106/jbjs.22.01149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores. METHODS We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors. RESULTS For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores. CONCLUSIONS Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lorraine A T Boakye
- Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Emily B Parker
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Chiodo
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric M Bluman
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Martin
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy T Smith
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Orringer M, Roberts H, Ngan A, Ward D. Influence of Demographic and Socioeconomic Factors on Hospital Distance for Total Knee Arthroplasty. Arthroplast Today 2023; 21:101131. [PMID: 37234597 PMCID: PMC10206785 DOI: 10.1016/j.artd.2023.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/28/2022] [Accepted: 03/08/2023] [Indexed: 05/28/2023] Open
Abstract
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.
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Affiliation(s)
- Matthew Orringer
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Heather Roberts
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alex Ngan
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Derek Ward
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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Hadad MJ, Rullán-Oliver P, Grits D, Zhang C, Emara AK, Molloy RM, Klika AK, Piuzzi NS. Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients. Clin Orthop Relat Res 2023; 481:254-264. [PMID: 36103368 PMCID: PMC9831172 DOI: 10.1097/corr.0000000000002392] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/11/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address. QUESTIONS/PURPOSES The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes. METHODS Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI. RESULTS In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 [95% confidence interval (CI) 0.31 to 0.59]; p < 0.001) and nonhome discharge (OR 0.39 [95% CI 0.27 to 0.56]; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 [95% CI -0.063 to -0.026]; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 [95% CI 0.024 to 0.059]; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 [95% CI -0.13 to -0.024]; p = 0.004; nonhome discharge: 0.060 [95% CI 0.016 to 0.11]; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 [95% CI 0.32 to 0.54]; p < 0.001), nonhome discharge (OR 0.44 [95% CI 0.33 to 0.60]; p < 0.001), 90-day readmission (OR 0.54 [95% CI 0.39 to 0.77]; p < 0.001), and 90-day ED admission (OR 0.60 [95% CI 0.45 to 0.79]; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 [95% CI -0.035 to -0.007]; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 [95% CI -0.016 to 0.040]; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 [95% CI -0.13 to -0.049]; p < 0.001; nonhome discharge: 0.046 [95% CI 0.014 to 0.078]; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group. CONCLUSION Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Matthew J. Hadad
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Pedro Rullán-Oliver
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chao Zhang
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Rudisill SS, Varady NH, Birir A, Goodman SM, Parks ML, Amen TB. Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:171-187.e18. [PMID: 35985539 DOI: 10.1016/j.arth.2022.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel S Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Rush Medical College of Rush University, Chicago, Illinois
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Aseal Birir
- Harvard Medical School, Boston, Massachusetts
| | - Susan M Goodman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael L Parks
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Brodeur PG, Boduch A, Kim KW, Cohen EM, Gil JA, Cruz AI. Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty. J Arthroplasty 2022; 37:S908-S918.e1. [PMID: 35151807 DOI: 10.1016/j.arth.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA). METHODS Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research. RESULTS In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities. CONCLUSION Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.
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Affiliation(s)
- Peter G Brodeur
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Abigail Boduch
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Kang Woo Kim
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric M Cohen
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph A Gil
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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15
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Demographics of Patients Traveling Notable Distances to Receive Total Knee Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202208000-00008. [PMID: 35960986 PMCID: PMC9377674 DOI: 10.5435/jaaosglobal-d-22-00159] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 11/18/2022]
Abstract
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.
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16
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Racial and Socioeconomic Differences in Distance Traveled for Elective Hip Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00004. [PMID: 35389931 PMCID: PMC8989782 DOI: 10.5435/jaaosglobal-d-22-00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 11/18/2022]
Abstract
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.
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Disparities across Diverse Populations in the Health and Treatment of Patients with Osteoarthritis. Healthcare (Basel) 2021; 9:healthcare9111421. [PMID: 34828468 PMCID: PMC8619799 DOI: 10.3390/healthcare9111421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
The study of disparities across diverse populations regarding the health and treatment of patients with osteoarthritis (OA) is recognized as a priority for investigation and action by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the American Academy of Orthopedic Surgeons (AAOS). OA is a common condition that increases with age, but with prevalence generally similar across racial and ethnic groups. However, disparities in the treatment of OA among racial, ethnic, and socioeconomic groups are well-documented and continue to rise and persist. The reasons are complex, likely involving a combination of patient, provider, and healthcare system factors. Treatment disparities among these different populations have an impact on clinical outcomes, healthcare, and productivity, and are projected to increase significantly with the growing diversity of the United States population. The aim of this short review is to summarize studies of racial, ethnic, and socioeconomic disparities among patients with OA in the United States, with a focus on prevalence, treatment utilization, and clinical and economic outcomes.
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