Socioeconomic Risk Factors for Poor Outcomes of Developmental Dysplasia of the Hip

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review

BACKGROUND

Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations.

QUESTIONS/PURPOSES

In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?

METHODS

On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed.

RESULTS

There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores.

CONCLUSION

Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A National Database Analysis: Does Cold Weather Affect the Surgical Intervention Rate for Developmental Dysplasia of the Hip in Children Under Five Years?

Background Cold weather in the first few months of life may increase the risk of a late diagnosis of developmental dysplasia of the hip (DDH). Early detection of DDH can often be treated non-surgically. The purpose of this study is to observe whether the rates of surgical intervention for DDH differ based on average outdoor temperatures in the winter months. Methods A retrospective observational study of DDH patients diagnosed from 2010 to 2021 was conducted using a national administrative database. Five geographic regions were defined based on the average temperatures in the coldest quarter of the year. The rates of DDH-related surgeries were compared across these temperature regions. Results A total of 55,911 patients ≤5 years old with a DDH diagnosis from 2010 to 2021 were identified in the database. When compared to the warmest region (Group 5), the coldest region (Group 1) had higher rates of open reduction (4.59% vs. 2.06%, p<0.001), adductor tenotomy (6.95% vs. 2.91%, p<0.001), femoral osteotomy (5.75% vs. 2.04%, p<0.001), pelvic osteotomy (5.27% vs. 2.04%, p<0.001), and total DDH surgeries (11.42% vs. 5.03%, p<0.001). Conclusion Children living in states with an average winter temperature of -6.17°C had an increased likelihood of requiring surgical intervention for DDH within the first five years of life.

Equity in the Developmental Dysplasia of the Hip (DDH) Diagnosis and Treatment: A Retrospective Cohort Study to Unravel the Effect of Area Deprivation and the Insurance Type

Background Timely diagnosis of developmental dysplasia of the hip (DDH) is crucial for implementing less invasive treatment. However, socioeconomic barriers may lead to late diagnoses. The Area Deprivation Index (ADI) is an indicator of the socioeconomic challenges experienced by patients and their families. The primary objective is to investigate if the age at which DDH is diagnosed and the treatment protocol are influenced by the ADI or the insurance type. Materials and methods Using International Classification of Diseases-Tenth Edition (ICD-10) codes, newly diagnosed DDH patients (age under 10 years) from 2020 to 2023 were retrospectively identified at our pediatric tertiary center. Patients were categorized into four groups based on ADI percentile: (1) 1-10th percentile, (2) 11-20th percentile, (3) 21-40th percentile, and (4) 41-100th percentile. They were also stratified by insurance type. Age at diagnosis and treatment protocol (non-operative vs. operative) were collected and compared between the different ADI groups and insurance groups. Operative treatment was defined as open reduction with or without femoral/pelvic osteotomy. Results A total of 327 patients satisfied the inclusion criteria and had available ADI scores for analysis. The average age at diagnosis was notably lower in ADI group 1 compared to all other ADI groups (p < 0.05) and considerably lower for patients with commercial insurance compared to those with public (p = 0.0002). The rate of surgical treatment was markedly lower in ADI group 1 compared to ADI groups 2 and 3 (both p < 0.05) and notably lower for those with commercial insurance compared to public (p = 0.0005). ADI groups 2-4 showed no significant differences in average age at diagnosis or surgical treatment rate. Conclusion The study demonstrates that socioeconomic factors affect the diagnosis and, consequently, the treatment course of DDH. Specifically, patients residing in areas with lower levels of deprivation tend to be diagnosed at a younger age and undergo surgical treatment less frequently.

Spanish language resources for patients with adolescent idiopathic scoliosis

BACKGROUND

Despite an increasing Spanish-speaking population, United States health care remains English dominant. The purpose of this study was to analyze the availability and readability of written patient education materials on adolescent idiopathic scoliosis (AIS) provided by the top pediatric orthopedic hospitals and the major professional societies.

METHODS

We performed a cross sectional analysis by determining the proportion of top pediatric orthopedic hospitals and major orthopedic professional societies providing English and Spanish resources. We also assessed the readability of information provided via three measures of readability. Descriptive, univariate, and multivariate analyses were performed.

RESULTS

Approximately 90% of hospitals provided English-language education, but only 37% of hospitals provided Spanish-language education. English and Spanish hospital resources were equivalent in readability across Reading Ease scores (p > 0.05), but Spanish-language resources ranked lower in grade level (8th grade vs. 10th grade, p = 0.01) and readability measures (9.6 vs. 11.6, p < 0.01). Two of the three major orthopedic professional organizations provided Spanish-language resources. The availability and readability of resources in states where more than 20% of the population spoke Spanish did not differ compared to institutions in states with fewer Spanish-speaking patients (p > 0.05).

CONCLUSIONS

The availability of Spanish-language resources for patients with AIS is limited, and the reading level for all educational resources is above the suggested level for patient education. Additional effort and resources should be allocated to the improvement of patient education as well as the development of Spanish-language resources for patients with AIS.

Efficacy of closed reduction for developmental dysplasia of the hip: midterm outcomes and risk factors associated with treatment failure and avascular necrosis

BACKGROUND

The purpose of this study was to evaluate the efficacy of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) and to investigate risk factors associated with CR failure and avascular necrosis (AVN) occurrence in follow-ups.

METHODS

The study retrospectively included 110 patients and 138 hips with DDH diagnosis that underwent closed reduction between February 2012 and November 2015 in our single tertiary medical institution. The failure rate of CR and the underlying risk factors were evaluated. Meanwhile, the incidence of AVN and the related risk factors among the successful CR cases were assessed.

RESULTS

The overall failure rate of DDH treated by CR in the present study was 31.16% (43/138). Risk factors for the CR failure were older age at the time of CR (≥ 18.35 month), large medical interval before CR (≥ 35.35 mm), and severer dislocation of the affected hip (IDHI grades III and IV). The incidence of AVN was 8.33% (6/72) in patients with successful CR at the last follow-up. No significant risk factors had been established in the present study that associated with the AVN occurrence.

CONCLUSIONS

For the treatment of DDH with CR, patients with younger age might achieve better outcomes; early diagnosis and early treatment might be the key point in the DDH treatment.