Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets

Racial and ethnic disparity in shoulder surgery: a systematic review

BACKGROUND

Health care disparity exists in utilization and delivery of musculoskeletal care and continues to be an obstacle for orthopedic health care providers to mitigate. Racial and ethnic disparities exist within various surgical fields including orthopedic surgery and are expected to continue to rise in upcoming years. The aim of this systematic review is to analyze the racial and ethnic disparities on utilization and outcomes after common shoulder surgical procedures.

METHODS

A primary literature search was performed using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases using comprehensive Medical Subject Headings and subject-heading search terms. Studies were included if they reported utilization and or outcomes across 2 or more racial/ethnic groups in patients (age >16) who underwent total shoulder arthroplasty (TSA), rotator cuff repair (RCR), arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of proximal humerus fracture (PHF). Baseline demographics, data on procedure utilization, perioperative measures including mortality, operative time, length of stay, readmission, and complications were extracted from included studies, and descriptive statistical analysis performed.

RESULTS

Eighteen studies were identified for full text review of which 13 found race and ethnicity as factors affecting utilization and outcomes in TSA, RCR, arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of PHF. Compared to White patients, Black patients were found to have decreased utilization, longer length of stay, and greater operative time and mortality after TSA; Black patients also had longer operative times and time to discharge, and lower levels of reported satisfaction after RCR. Hispanic/Latino ethnicity was reported as an independent risk factor for postoperative falls following TSA. Hispanic/Latino and Black patients have a higher risk of delayed surgery and greater risk of readmission after surgical treatment of PHF compared to patients of White race.

CONCLUSION

This systematic review highlights the limited literature reporting the existence of racial and ethnic disparities in utilization and outcomes after common shoulder surgical procedures. Additionally, there is a paucity of studies exploring the underlying etiology of racial and ethnic disparity in outcomes after shoulder surgery. More research is necessary to pave the way for evidence-based action plans to mitigate health care disparities after shoulder surgeries, but this review serves as a baseline for where efforts in direct improvement can begin.

Racial and Ethnic Disparities in Prescription of a Novel Agent in Medical Management of Primary Open-Angle Glaucoma

PURPOSE

To investigate racial and ethnic inequalities in prescription of Netarsudil, one of two anti-glaucoma medications with a novel mechanism to be introduced in the past two decades, among patients with primary open-angle glaucoma.

METHODS

This retrospective cohort matched study, based on electronic health records consisting of 92 million patients in the U.S, utilized Propensity Score Match, Relative Risk, Kaplan-Meier survival, and Chi-Square analysis to identify differences in rates of Netarsudil prescribing between racial and ethnic groups (non-Hispanic White, non-Hispanic Black, non-Hispanic Other Race, and Hispanic).

RESULTS

Among the sample of patients that met Primary Open-Angle Glaucoma inclusion criteria (55,942), more White patients were prescribed Netarsudil than Black; (RR:1.24, 95% CI: 1.15-1.34) and Hispanic; (RR:1.63, 95% CI: 1.29-2.07) patients. White patients had higher prescription rates than Black patients in the Midwest (6.5% vs 4.2%; p < 0.0001) and West (11.2% vs 7.1%; p = 0.0002), higher rates than Hispanic patients in the South (4.9% vs. 2.0%; p < 0.0001) and West (11.2% vs. 7.8%; p < 0.008), but lower rates than Black patients in the Northeast (7.2% vs. 13.2%; p < 0.0001).

CONCLUSIONS

Differences in Netarsudil prescription rates within the United States exist between White and Black patients, and White and Hispanic patients. These differences exist when stratified by regions within the U.S. by varying degrees. Future studies are needed to investigate factors contributing to disparities in accessing new medications and to identify ways to eliminate such barriers to improve equity in care of glaucoma patients, especially among those historically disadvantaged.

The effects of social determinants of health on rotator cuff repair utilization and outcomes: a systematic review

Background

Since various social determinants of health (SDOH) have the potential to impact the utilization and postoperative outcomes of rotator cuff repair (RCR), a review of the literature is warranted. Therefore, the purpose of this systematic review was to evaluate the effects of SDOH on RCR utilization and postoperative outcomes in order to recognize external factors that may influence patients' access to RCR and optimal clinical outcomes.

Methods

Search terms related to RCR, utilization, outcomes, and SDOH were used to identify studies that reported associations between any SDOH (as defined by the World Health Organization) and RCR utilization, access, cost, or postoperative outcomes. Articles that did not isolate RCR or did not evaluate an SDOH were excluded. Nonrandomized studies were evaluated for study quality using the Methodological Index for Nonrandomized Studies score. Due to the heterogeneity of the reported data, only qualitative analysis was possible.

Results

Overall, 842 articles were considered for inclusion and 14 studies were included in qualitative analysis. The average Methodological Index for Nonrandomized Studies score of included studies was 14.1 ± 5.0. The SDOH most frequently evaluated were insurance status and race/ethnicity. Non-White race is associated with lower odds of surgery and physical therapy (PT) utilization, as well as delayed treatment. Similarly, public insurance is associated with lower PT and surgery utilization rates and decreased acceptance for postoperative PT. Postoperatively, public insurance is associated with worse patient-reported outcome scores and lower return to work rates.

Conclusion

Various SDOH can influence access, utilization, and outcomes of RCR. Orthopedic surgeons should be aware of how factors of race and insurance type can influence a patient's treatment and recovery after RCR.

Concomitant Procedures, Black Race, Male Sex, and General Anesthesia Show Fair Predictive Value for Prolonged Rotator Cuff Repair Operative Time: Analysis of the National Quality Improvement Program Database Using Machine Learning

PURPOSE

To develop machine learning models using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database to predict prolonged operative time (POT) for rotator cuff repair (RCR), as well as use the trained machine learning models, cross-referenced with traditional multivariate logistic regression (MLR), to determine the key perioperative variables that may predict POT for RCR.

METHODS

Data were obtained from a large national database (ACS-NSQIP) from 2021. Patients with unilateral RCR procedures were included. Demographic, preoperative, and operative variables were analyzed. An MLR model and various other machine learning techniques, including random forest (RF) and artificial neural network, were compared using area under the curve, calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model.

RESULTS

A total of 6,690 patients met inclusion criteria. The RF machine learning model had the highest area under the curve upon internal validation (0.706) and the lowest Brier score (0.15), outperforming the other models. The RF model also demonstrated strong performance upon assessment of the calibration curves (slope = 0.86, intercept = 0.08) and decision curve analysis. The model identified concomitant procedure, specifically labral repair and biceps tenodesis, as the most important variable for determining POT, followed by age <30 years, Black or African American race, male sex, and general anesthesia.

CONCLUSIONS

Despite the advanced machine learning models used in this study, the ACS-NSQIP data set was only able to fairly predict POT following RCR. The RF model identified concomitant procedures, specifically labral repair and biceps tenodesis, as the most important variables for determining POT. Additionally, demographic factors such as age <30 years, Black race, and general anesthesia were significant predictors. While male sex was identified as important in the RF model, the MLR model indicated that its predictive value is primarily in conjunction with specific procedures like biceps tenodesis and subacromial decompression.

LEVEL OF EVIDENCE

Level IV, retrospective comparative prognostic trial.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Social determinants of health influence clinical outcomes of patients undergoing rotator cuff repair: a systematic review

BACKGROUND

Social determinants of health (SDOH) are the collection of environmental, institutional, and intrinsic conditions that may bias access to, and utilization of, health care across an individual's lifetime. The effects of SDOH are associated with disparities in patient-reported outcomes after hip and knee arthroplasty, but its impact on rotator cuff repair (RCR) is poorly understood. This study aimed to investigate the influences that SDOH have on accessing appropriate orthopedic treatment, as well as its effects on patient-reported outcomes following RCR.

METHODS

This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and guidelines outlined by the Cochrane Collaboration. A search of PubMed, the Cochrane Library, and Embase from inception until March 2022 was conducted to identify studies reporting at least 1 SDOH and its effect on access to health care, clinical outcomes, or patient-reported outcomes following RCR. The search term was created with reference to the PROGRESS-Plus framework. Methodological quality of included primary studies was appraised using the Newcastle-Ottawa Scale (NOS) for nonrandomized studies, and the Cochrane Risk of Bias Tool for randomized studies.

RESULTS

Thirty-two studies (level I-IV evidence) from 18 journals across 7 countries, published between 1999 and 2022, met inclusion criteria, including 102,372 patients, 669 physical therapy (PT) clinics, and 71 orthopedic surgery practices. Multivariate analysis revealed female gender, labor-intensive occupation and worker's compensation claims, comorbidities, tobacco use, federally subsidized insurance, lower education level, racial or ethnic minority status, low-income place of residence and low-volume surgery regions, unemployment, and preoperative narcotic use contribute to delays in access to health care and/or more severe disease state on presentation. Black race patients were found to have significantly worse postoperative clinical and patient-reported outcomes and experienced more pain following RCR. Furthermore, Black and Hispanic patients were more likely to present to low-volume surgeons and low-volume facilities. A lower education level was shown to be an independent predictor of poor surgical and patient-reported outcomes as well as increased pain and worse patient satisfaction. Patients with federally subsidized insurance demonstrated significantly worse postoperative clinical and patient-reported outcomes CONCLUSIONS: The impediments created by SDOH lead to worse clinical and patient-reported outcomes following RCR including increased risk of postoperative complications, failed repair, higher rates of revision surgery, and decreased ability to return to work. Orthopedic surgeons, policy makers, and insurers should be aware of the aforementioned SDOH as markers for characteristics that may predispose to inferior outcomes following RCR.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes

Background

There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed.

Results

Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P _trend < .0001).

Conclusion

Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.