Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

Narrative review and call to action on reporting and representation in orthobiologics research for knee osteoarthritis

Osteoarthritis affects a significant portion of U.S. adults, and knee osteoarthritis contributes to 80% of disease burden. Previous data have shown that non-White patient populations often report worse symptoms and less favorable outcomes following arthroplasty, a definitive treatment for knee osteoarthritis. There is a lack of demographics data on race/ethnicity, as well as socioeconomic status (SES) and social determinants of health (SDOH), in knee osteoarthritis treatment guidelines and knee arthroplasty research. In addition, there is underrepresentation of non-White patient populations in the existing treatment guidelines for knee osteoarthritis. Over the past decade, orthobiologics have emerged as an alternative to surgical intervention. Our hypothesis is that there would be a similar lack of reporting of demographics data and underrepresentation of non-White populations in studies pertaining to orthobiologics, including evaluating differences in outcomes. This study reviewed U.S.-based research in orthobiologics as a treatment option for knee osteoarthritis. We identified a lack of demographics reporting in terms of race/ethnicity, and none of the studies reported SES or SDOH. Non-White populations were underrepresented; White patients contributed to 80% or more of all study populations that reported race/ethnicity. None studied the correlation between symptoms and outcome measures, and the race/ethnicity, SES, and SDOH of the patients. Based on a review of existing literature, we strongly advocate for ongoing research encompassing patients of all races/ethnicities, SES, and SDOH, and an exploration into potential variations in symptoms and outcomes among distinct population subgroups. Furthermore, SES barriers may influence health care delivery on orthobiologics for disadvantaged populations.

Limited Health Literacy Among Patients With Orthopedic Injuries: A Cross-sectional Survey of Patients Who Underwent Orthopedic Trauma Surgery in a County Hospital Setting

BACKGROUND

Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes.

MATERIALS AND METHODS

This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores.

RESULTS

Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively).

CONCLUSION

Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 202x;4x(x):xx-xx.].

Mixed-Methods Study of Disability Self-Management in Mexican Americans With Osteoarthritis

BACKGROUND

Health disparities in osteoarthritis (OA) outcomes exist both in the occurrence and treatment of functional limitation and disability for Mexican Americans. Although the effect of self-management of chronic illness is well established, studies demonstrate little attention to self-management of function or disability, despite the strong potential effect on both and, consequently, on patients' lives.

OBJECTIVE

The purpose of this study pilot was to develop and test key variable relationships for a measure of disability self-management among Mexican Americans.

METHODS

In this sequential, two-phased, mixed-methods, biobehavioral pilot study of Mexican American women and men with OA, a culturally tailored measure of disability self-management was created, and initial relationships among key variables were explored.

RESULTS

First, a qualitative study of 19 adults of Mexican American descent born in Texas (United States) or Mexico was conducted. The Mexican American Disability Self-Management Scale was created using a descriptive content analysis of interview data. The scale was tested and refined, resulting in 18 items and a descriptive frequency of therapeutic management efforts. Second, correlations between study variables were estimated: Disability and function were negatively correlated. Disability correlated positively with social support and activity effort. Disability correlated negatively with disability self-management, pain, and C-reactive protein. Function was positively correlated with age, pain, and depression. Liver enzymes (alanine transaminase) correlated positively with pain and anxiety.

DISCUSSION

This mixed-methods study indicates directions for further testing and interventions for disability outcomes among Mexican Americans.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Overcoming the Barriers to Diversity in Orthopaedic Surgery: A Global Perspective

BACKGROUND

Diversity in orthopaedics continues to lag behind that in other surgical specialties. This pattern exists globally and is not unique to gender or race. This review offers a global perspective on overcoming the barriers to diversity in orthopaedics.

METHODS

A literature search of MEDLINE and Embase was conducted and a narrative review was undertaken. Publications that discussed any aspect of diversity or solutions to diversity within orthopaedics or academic orthopaedics were identified.

RESULTS

A total of 62 studies were included. Studies showed that diversity in orthopaedic training is limited by structural barriers such as long hours, requirements to relocate during training, training inflexibility, and a lack of exposure to orthopaedics. Implicit bias during the selection process for training, discrimination, and a lack of role models are additional barriers that are experienced by both minority and female surgeons. The global lack of diversity suggests that there are also inherent "cultural barriers" that are unique to orthopaedics; however, these barriers are not uniformly experienced. Perceptions of orthopaedics as promoting an unhealthy work-life balance and the existence of a "boys' club" must be addressed. Strong, committed leaders can embed cultural norms, support trainees, and act as visible role models. Targeted efforts to increase diverse recruitment and to reduce bias in selection processes for medical school and specialty training will increase diversity in the "training pipeline."

CONCLUSIONS

Diversity in orthopaedics continues to lag behind that in other specialties. Increasing diversity is important for providing a more inclusive training environment, improving patient care, and reducing health disparities. Structural and cultural barriers need to be addressed to improve diversity in orthopaedics. Promoting a culture supportive of all surgeons is essential to reframing perceptions that may prevent individuals from even considering a career as an orthopaedic surgeon. Changing attitudes require focused efforts from committed leadership in a "top-down" approach that prioritizes diversity. The efforts from national bodies seeking to tackle the lack of diversity, as well as the establishment of organizations committed to diversity, such as the International Orthopaedic Diversity Alliance, provide reasons to be optimistic for the future.

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

Hospital characteristics and perioperative complications of Hispanic patients following reverse shoulder arthroplasty-a large database study

BACKGROUND

Hispanic patients are the youngest and fastest-growing ethnic group in the USA. Many of these patients are increasingly met with orthopedic issues, often electing to undergo corrective procedures such as reverse shoulder arthroplasty (RSA). This patient population has unique medical needs and has been reported to have higher incidences of perioperative complications following major procedures. Unfortunately, there is a lack of information on the hospitalization data and perioperative complications in Hispanic patients following procedures such as RSA. This project aimed to query the Nationwide Inpatient Sample (NIS) database to assess patient hospitalization information, demographics, and the prevalence of perioperative complications among Hispanic patients who received RSA.

METHODS

Information from 2016-2019 was queried from the NIS database. Demographic information, incidences of perioperative complications, length of stay, and costs of care among Hispanic patients undergoing RSA were compared to non-Hispanic patients undergoing RSA. A subsequent propensity matching was conducted to consider preoperative comorbidities.

RESULTS

The query of NIS identified 59,916 patients who underwent RSA. Of this sample, 2,656 patients (4.4%) were identified to be Hispanic, while the remaining 57,260 patients (95.6%) were found to belong to other races (control). After propensity matching, Hispanic patients had a significantly longer LOS (median = 1.4 days) than the patients in the control group (median = 1.0, P < 0.001). The Hispanic patients (89,168.5 USD) had a significantly higher cost of care than those in the control group (67,396.1 USD, P < 0.001). In looking at postoperative complications, Hispanic patients had increased incidences of acute renal failure (Hispanics: 3.1%, control group: 1.1%, P = 0.03) and blood loss anemia (Hispanics: 12.7%, control group: 10.9%, P = 0.03).

CONCLUSIONS

Hispanic patients had significantly longer lengths of stay, higher costs of care, and higher rates of perioperative complications compared to the control group. For patients who are Hispanic and undergoing RSA, this information will aid doctors in making comprehensive decisions regarding patient care and resource allocation.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance

Purpose

To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction.

Methods

A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups.

Results

In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P = .036).

Conclusions

Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Barriers and strategies for recruiting participants who identify as racial minorities in musculoskeletal health research: a scoping review

Objective

Visible minorities are disproportionately affected by musculoskeletal disorders (MSD) and other diseases; yet are largely underrepresented in health research. The purpose of this scoping review was to identify barriers and strategies associated with increasing recruitment of visible minorities in MSD research.

Methods

Electronic databases (MEDLINE, EMBASE, CINAHL, and PsycInfo) were searched. Search strategies used terms related to the concepts of 'race/ethnicity', 'participation', 'research' and 'musculoskeletal'. All research designs were included. Two reviewers independently screened titles and abstracts, completed full-text reviews, and extracted data. Papers that did not focus on musculoskeletal research, include racial minorities, or focus on participation in research were excluded. Study characteristics (study location, design and methods; sample characteristics (size, age, sex and race); MSD of interest) as well as barriers and strategies to increasing participation of visible minorities in MSD research were extracted from each article and summarized in a table format.

Results

Of the 4,282 articles identified, 28 met inclusion criteria and were included. The majority were conducted in the United States (27 articles). Of the included studies, the groups of visible minorities represented were Black (25 articles), Hispanic (14 articles), Asian (6 articles), Indigenous (3 articles), Middle Eastern (1 article), and Multiracial (1 article). The most commonly cited barriers to research participation were mistrust, logistical barriers (e.g., transportation, inaccessible study location, financial constraints), and lack of awareness or understanding of research. Strategies for increasing diversity were ensuring benefit of participants, recruiting through sites serving the community of interest, and addressing logistical barriers.

Conclusion

Understanding the importance of diversity in MSD research, collaborating with communities of visible minorities, and addressing logistical barriers may be effective in reducing barriers to the participation of visible minorities in health research. This review presents strategies to aid researchers in increasing inclusion in MSD-related research.

Influence of Demographic and Socioeconomic Factors on Hospital Distance for Total Knee Arthroplasty

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.

Racial/Ethnic Disparities in Physical Therapy Utilization After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities.

METHODS

TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses.

RESULTS

Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each).

DISCUSSION

In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately.

LEVEL OF EVIDENCE

Level III.

The Use of Race in Risk Assessment Tools Contributes to Systemic Racism

Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.

Racial variation in healthcare resource utilization and expenditures in knee/hip osteoarthritis patients: a retrospective analysis of a Medicaid population

BACKGROUND

Osteoarthritis (OA) is a leading cause of chronic pain and disability. Prior studies have documented racial disparities in the clinical management of OA. The objective of this study was to assess the racial variations in the economic burden of osteoarthritis within the Medicaid population.

METHODS

We conducted a retrospective observational study using the MarketScan Multi-State Medicaid database (2012-2019). Newly diagnosed, adult, knee and/or hip OA patients were identified and followed for 24 months. Demographic and clinical characteristics were collected at baseline; outcomes, including OA treatments and healthcare resource use (HCRU) and expenditures, were assessed during the 24-month follow-up. We compared baseline patient characteristics, use of OA treatments, and HCRU and costs in OA patients by race (White vs. Black; White vs. Other) and evaluated racial differences in healthcare costs while controlling for underlying differences. The multivariable models controlled for age, sex, population density, health plan type, presence of non-knee/hip OA, cardiovascular disease, low back pain, musculoskeletal pain, presence of moderate to severe OA, and any pre-diagnosis costs.

RESULTS

The cohort was 56.7% White, 39.9% Black and 3.4% of Other race (American Indian/Alaska Native, Hispanic, Asian, Native Hawaiian/Other Pacific Islander, two or more races and other). Most patients (93.8%) had pharmacologic treatment for OA. Inpatient admission during the 24-month follow-up period was lowest among Black patients (25.8%, p < .001 White vs. Black). In multivariable-adjusted models, mean all-cause expenditures were significantly higher in Black patients ($25,974) compared to White patients ($22,913, p < .001). There were no significant differences between White patients and patients of Other race ($22,352).

CONCLUSIONS

The higher expenditures among Black patients were despite a lower rate of inpatient admission in Black patients and comparable length and number of hospitalizations in Black and White patients, suggesting that other unmeasured factors may be driving the increased costs among Black OA patients.

Taking the Long Way to Care: Who is Traveling Farthest to Undergo Elective Total Hip Arthroplasty?

Background

Disparities in access to total hip arthroplasty (THA) exist. The purpose of this study is to examine how distance traveled to undergo elective THA correlates with sociodemographic variables and postoperative outcomes.

Material and methods

The Healthcare Cost and Utilization Project New York and Florida state inpatient databases were used to identify patients who underwent elective THA between 2006 and 2014. Data from the American Hospital Association and United States Postal Service were used to calculate the distance patients traveled to receive THA, and only those who traveled more than 25 miles were included. We stratified patients into 4 groups based on their distance traveled (25-50 miles, 50.01-100 miles, 100.01-500 miles, and >500.01 miles) and compared demographic characteristics and postoperative outcomes between groups.

Results

Age, race, insurance provider, zip code income quartile, and Charlson Comorbidity Index scores were each significantly associated with travel distance (P < .001) among our cohort of 25,734 patients. Patients who were older, were white, had Medicare insurance coverage, lived in zip codes with a higher median household income, and had increased comorbidities were more likely to travel the farthest to receive care. There were minimal associations between travel distance and postoperative outcomes.

Conclusion

There may be specific demographic groups who either are forced to travel long distances to receive care or have the resources to seek out and travel to distant hospitals in an effort to receive optimal care. Understanding the interconnected relationships between demographic variables is necessary to address disparities in access to specialized orthopedic surgical care.

Neighborhood-Level Socioeconomic Deprivation, Rurality, and Long-Term Outcomes of Patients Undergoing Total Joint Arthroplasty: Analysis from a Large, Tertiary Care Hospital

Objective

To assess the impact of neighborhood-level socioeconomic status factors (area deprivation index [ADI] and rural classification) and their interaction with individual-level socioeconomic status (education-level) on long-term outcomes following total joint arthroplasty (TJA) surgery.

Patients and Methods

This was a cohort study of 46,828 TJA surgeries performed on patients at a tertiary care hospital between January 1, 2000 and December 31, 2019. Cox proportional hazards models were used to examine the association between ADI and rurality and their interaction with individual-level education on the risk of periprosthetic joint infections, revision surgery, and mortality.

Results

At the time of surgery, 2589 (6%) patients lived in the most deprived neighborhoods (ADI quintile >80%) and 10,728 (23%) lived in small isolated rural towns. Patients from the most deprived neighborhoods were more likely to experience revision surgery (hazard ratio, [HR], 1.39; 95% CI, 1.10-1.76) and mortality (HR, 1.24; 95% CI, 1.09-1.42). Patients from small rural towns were also more likely to undergo revision surgery (HR, 1.14; 95% CI, 1.01-1.28). The mortality risk was 13%, 18%, and 24% higher for patients in the 3 highest ADI quintiles than those from the lowest quintile. Education gradient was more notable in the least deprived neighborhoods than in the most deprived neighborhoods.

Conclusion

Neighborhood disadvantage and rurality are negatively associated with the risk of revision surgery and both independently and in interaction with individual-level education with the risk of mortality. There is a need for population-level health interventions to mitigate area-based socioeconomic disadvantages in TJA.

Association of Rurality and Neighborhood Level Socioeconomic Deprivation with Perioperative Health Status in Total Joint Arthroplasty Patients: Analysis from a Large, Tertiary Care Hospital

BACKGROUND

Individual socioeconomic status (SES) is associated with disparities in access to care and worse outcomes in total joint arthroplasty (TJA). Neighborhood-level SES measures are sometimes used as a proxy for individual-level SES, but the validity of this approach is unknown. We examined neighborhood level SES and rurality on perioperative health status in TJA.

METHODS

The study population comprised 46,828 TJA surgeries performed at a tertiary care hospital. Community area deprivation index (ADI) was derived from the 2015 American Census Survey. Logistic regression was used to examine perioperative characteristics by ADI and rurality.

RESULTS

Compared to patients from the least deprived neighborhoods, patients from the most deprived neighborhoods were likely to be female (odds ratioOR 1.46, 95% confidence interval CI: 1.33-1.61), non-white (OR 1.36, 95% CI: 1.13-1.64), with education high school or less (OR 4.85, 95% CI: 4.35-5.41), be current smokers (OR 2.20, 95% CI: 1.61-2.49), have BMI>30 kg/m² (OR 1.43, 95% CI: 1.30-1.57), more limitation on instrumental activities of daily living (OR 1.75, 95% CI: 1.55-1.97) and American Society of Anesthesiologists (ASA) score > II (OR 2.0, 95% CI: 1.11-1.37). There was a progressive association between the degree of area level deprivation with preexisting comorbidities. Patients from rural communities were more likely to be male, white, have body mass index (BMI)>30 kg/m² and lower education levels. However, rurality was either not associated or negatively associated with comorbidities.

CONCLUSION

TJA patients from lower SES neighborhoods have worse behavioral risk factors and higher comorbidity burden than patients from higher SES neighborhoods. Patients from rural communities have worse behavioral risk factors but not comorbidities.

Demographics of Patients Traveling Notable Distances to Receive Total Knee Arthroplasty

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.

Trends and Racial/Ethnic Differences in Health Care Spending Stratified by Gender among Adults with Arthritis in the United States 2011-2019

The purpose of this study was to determine if there were racial/ethnic differences and patterns for individual office-based visit expenditures by gender among a nationally representative sample of adults with arthritis. We retrospectively analyzed pooled data from the 2011 to 2019 Medical Expenditure Panel Survey of adults who self-reported an arthritis diagnosis, stratified by gender (men = 13,378; women = 33,261). Our dependent variable was office-based visit expenditures. Our independent variables were survey year (categorized as 2011-2013, 2014-2016, 2017-2019) and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, non-Hispanic other/multiracial). We conducted trends analysis to assess for changes in expenditures over time. We utilized a two-part model to assess differences in office-based expenditures among participants who had any office-based expenditure and then calculated the average marginal effects. The unadjusted office-based visit expenditures increased significantly across the study period for both men and women with arthritis, as well as for some racial and ethnic groups depending on gender. Differing racial and ethnic patterns of expenditures by gender remained after accounting for socio-demographic, healthcare access, and health status factors. Delaying care was an independent driver of higher office-based expenditures for women with arthritis but not men. Our findings reinforce the escalating burden of healthcare costs among U.S. adults with arthritis across genders and certain racial and ethnic groups.

Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review

Background

Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments.

Objectives

The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA.

Data sources and methods

A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results

The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations.

Conclusion

This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.

A Retrospective Analysis of 1,595 Cases: Comparing the Characteristics of Total Knee Arthroplasty between Tibetans Living in the Plateau and Han of the Sichuan Basin

Background

Total knee arthroplasty is an effective treatment for end-stage knee arthritis. Studies' date have shown that the demand for knee replacements continues to increase worldwide. Although racial disparities have been previously reported in the utilization of total knee arthroplasty in western countries, however, there are few similar studies in China.

Objectives

Retrospective analysis of medical records identified the characteristics of Tibetan patients who had undergone total knee arthroplasty living in plateau and their differences with Hans living in Sichuan Basin.

Methods

The patients with unilateral primary total knee arthroplasty in Sichuan Orthopedic Hospital from 2015 to 2020 were enrolled. Analyze and compare the demographic characteristics (age, body mass index, and occupation) and pathogenesis characteristics (disease duration, exacerbation period, treatment methods, etc.) of the plateau Tibetans and the Hans of the Sichuan Basin.

Results

1595 eligible patients were reviewed, including 541 Tibetan patients and 1054 Han patients, The average age of Tibetan patients was lower than that of Han patients (P < 0.001); the average BMI index of Tibetan patients was higher than that of Han patients (P < 0.001). And obese people account for more; the occupational distribution of Tibetan patients is more concentrated, mainly farmers. Tibetan patients have a longer course of disease than Han patients (P < 0.001).

Conclusions

The social background and geographical environment of the Tibetan population are different from those of the Han. Tibetans living on plateaus have an earlier illness, a longer course of illness, a more obvious trend of younger, age and fewer opportunities for regular treatment during the illness.

Racial and Socioeconomic Differences in Distance Traveled for Elective Hip Arthroplasty

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.