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Schmerler J, Haft M, Nelson S, Srikumaran U, Best MJ. Payer Status and Racial Disparities in Time to Surgery for Emergent Orthopaedic Procedures. J Am Acad Orthop Surg 2024:00124635-990000000-01030. [PMID: 38996182 DOI: 10.5435/jaaos-d-23-01136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/23/2024] [Indexed: 07/14/2024] Open
Abstract
INTRODUCTION Delay in surgical management for orthopaedic emergencies and severe fracture types can result in notable morbidity and even mortality for patients. Disparities in various facets of orthopaedic care have been identified based on race/ethnicity, socioeconomic status, and payer status, but disparities in time to surgery have been poorly explored. The purpose of this study was, therefore, to investigate whether disparities exist in time to emergent orthopaedic surgery. METHODS Patients who underwent surgery for hip fracture, femur fracture, pelvic fracture, septic knee, septic hip, or cauda equina syndrome over 2012 to 2020 were identified using national data. Multivariable linear regression models were constructed, controlling for age, sex, race/ethnicity, payer status, socioeconomic status, hospital setting, and comorbidities to examine the effect of payer status and race/ethnicity, on time to surgery. RESULTS Over 2012 to 2020, 247,370 patients underwent surgery for hip fracture, 64,827 for femur fracture, 14,130 for pelvic fracture, 14,979 for septic knee, 3,205 for septic hip, and 4,730 for cauda equina syndrome. On multivariable analysis, patients with Medicaid experienced significantly longer time to surgery for hip fracture, femur fracture, pelvic fracture, septic knee, and cauda equina syndrome (P < 0.05 all). Black patients experienced longer time to surgery for hip fracture, femur fracture, septic knee, septic hip, and cauda equina syndrome, and Hispanic patients experienced longer time to surgery for hip fracture, femur fracture, pelvic fracture, and cauda equina syndrome (P < 0.05 all). DISCUSSION The results of this study demonstrate that Medicaid-insured patients, and often minority patients, experience longer delays to surgery than privately insured and White patients. Future work should endeavor to identify causes of these disparities to promote creation of policies aimed at improving timely access to care for Medicaid-insured and minority patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jessica Schmerler
- From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Dhanjani SA, Gomez G, Rogers D, LaPorte D. Are There Racial and Ethnic Disparities in Management and Outcomes of Surgically Treated Distal Radius Fractures? Hand (N Y) 2024; 19:471-480. [PMID: 36196925 PMCID: PMC11067843 DOI: 10.1177/15589447221124248] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Racial/ethnic disparities have been demonstrated across multiple orthopedic sub-specialties. There is a paucity of literature examining disparities in distal radius fracture (DRF) management. METHODS Using the National Surgical Quality Improvement Program database, we analyzed 15 559 non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic adults who underwent open reduction and internal fixation for DRF from 2013 to 2019. We evaluated time from hospital admission to surgery and length of stay using Poisson regression. Deep venous thrombosis, pulmonary embolism (PE), and wound complications were reported using descriptive statistics. Thirty-day reoperation and readmission were analyzed using binary logistic regression. RESULTS Wait time to surgery was longer for Hispanic patients than NH White patients (incidence rate ratio [IRR]: 2.54, P < .001); this narrowed over time (IRR: 0.944, P = .047). Length of stay was longer for NH Black (IRR: 1.78, P < .001) and Hispanic patients (IRR: 1.83, P < .001), but shorter for NH Asian (IRR: 0.715, P = .019) than NH White patients; this temporally narrowed for NH Black patients (IRR: 0.908, P = .001). Deep venous thrombosis, PE, and wound complications occurred at a rate less than 0.30% across all groups. Hispanic patients were less likely to undergo reoperation than NH White patients (odds ratio [OR]: 0.254, P = .003). While there was no difference in readmission between groups in the aggregated study period, NH Black patients experienced a temporal increase in readmissions relative to NH White patients (OR: 1.40, P = .038). CONCLUSIONS Racial and ethnic disparities exist in DRF management. Further investigation on causes for and solutions to combat these disparities in DRF care may help improve the inequities observed.
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Affiliation(s)
| | - Gabriela Gomez
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Davis Rogers
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dawn LaPorte
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Mani K, Kleinbart E, Schlumprecht A, Golding R, Akioyamen N, Song H, De La Garza Ramos R, Eleswarapu A, Yang R, Geller D, Hoang B, Fourman MS. Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer. J Am Acad Orthop Surg 2024; 32:e346-e355. [PMID: 38354415 DOI: 10.5435/jaaos-d-23-00718] [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: 08/03/2023] [Accepted: 12/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine (Mani, Kleinbart, Golding, and Song), the Department of Neurological Surgery, Montefiore Einstein (Schlumprecht, and De La Garza Ramos), and the Department of Orthopaedic Surgery, Montefiore Einstein, Bronx, NY (Akioyamen, Eleswarapu, Yang, Geller, Hoang, and Fourman)
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Liu C, Varady N, Chruscielski CM, Zhang D, Blazar P, Earp BE. Clinic Study Completion Rate in Orthopedic Surgery. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:12-15. [PMID: 38313622 PMCID: PMC10837181 DOI: 10.1016/j.jhsg.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/29/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose The primary aim of this study is to determine the rate of completion of clinic-based study orders. Secondarily, we attempt to determine factors associated with study incompletion. Methods This retrospective study included 591 clinic-based studies that were ordered for 510 patients at the time of clinical evaluation at a single medical center between April 8, 2018 and August 22, 2019. Inclusion criteria were studies ordered in a hand clinic for consecutive adult patients to be completed after the visit. Exclusion criteria included pediatric patients and routine radiographs obtained prior to the visit. Invasive studies were defined as studies with a significant procedural component, such as aspirations, injections and electromyography/nerve conduction (electrodiagnostic) studies (EDS). Blood tests and imaging were considered noninvasive. Patient demographics and study completion rates were collected through chart reviews. Univariate and bivariate analyses were performed, and P <.05 was considered significant. Results The overall clinic-based study completion rate was 94.2%, with the highest incompletion rates seen in invasive studies (8.3%, n = 34) compared to noninvasive studies (3.3%, n = 10). Within the invasive study category, EDS had the highest rate of incompletion (11.4%) and contributed to the majority of incompletions in the invasive cohort (20/24). The median time to study completion was 7 days (interquartile range [IQR] 2-21). Race, gender, English as primary language, marriage status, insurance type, and distance from facility were similar between completed and noncompleted studies. Conclusion Study completion rates were similar between all patients regardless of race, gender, and other social economic variables. Invasive studies, particularly EDS, had higher rates of incompletion and can be barriers to patients receiving additional care. Type of study/level of evidence Therapeutic III.
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Affiliation(s)
- Christina Liu
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nathan Varady
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
| | - Cassandra M. Chruscielski
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
| | - Dafang Zhang
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philip Blazar
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Brandon E. Earp
- Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Amen TB, Chatterjee A, Rudisill SS, Joseph GP, Nwachukwu BU, Ode GE, Williams RJ. National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States. Orthop J Sports Med 2023; 11:23259671231187447. [PMID: 37655237 PMCID: PMC10467402 DOI: 10.1177/23259671231187447] [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: 03/02/2023] [Accepted: 04/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. Purpose To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Study Design Descriptive epidemiology study. Methods The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. Results During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Conclusion Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.
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Affiliation(s)
- Troy B. Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Abhinaba Chatterjee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Samuel S. Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriel P. Joseph
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Benedict U. Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriella E. Ode
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
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Best MJ, Fedorka CJ, Belniak RM, Haas DA, Zhang X, Armstrong AD, Abboud JA, Jawa A, O'Donnell EA, Simon JE, Wagner ER, Malik M, Gottschalk MB, Khan AZ, Updegrove GF, Makhni EC, Warner JJP, Srikumaran U. The impact of the COVID-19 pandemic on racial disparities in patients undergoing total shoulder arthroplasty in the United States. JSES Int 2023; 7:252-256. [PMID: 36405932 PMCID: PMC9651989 DOI: 10.1016/j.jseint.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the United States and to determine whether these disparities were affected by the COVID-19 pandemic. Methods Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April to December from 2019 to 2020. Utilization was assessed for White, Black, Hispanic, and Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age, sex, CMS-hierarchical condition categories (HCC) score, dual enrollment (proxy for socioeconomic status), time-fixed effects, and core-based statistical area fixed effects was used to study difference across groups. Results In 2019, the TSA volume per 1000 beneficiaries was 1.51 for White and 0.57 for non-White, with a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P < .01). There was an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference; 8.7%, P = .02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%, P = .05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. Conclusions During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA, while disparities were less apparent for proximal humerus fracture.
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Affiliation(s)
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Robert M Belniak
- Department of Orthopaedic Surgery and Sports Medicine, Starling Physicians Group, New Britain, CT, USA
| | | | | | - April D Armstrong
- Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joseph A Abboud
- Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA.,Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Evan A O'Donnell
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston Shoulder Institute, Boston, MA, USA
| | - Jason E Simon
- Department of Orthopaedic Surgery, Harvard Medical School, Newton-Wellesley Hospital, Boston, MA, USA
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | | | - Adam Z Khan
- Northwest Permanente Physicians and Surgeons, Clackamas, OR, USA
| | - Gary F Updegrove
- Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eric C Makhni
- Department of Orthopaedic Surgery, Sports Medicine, Henry Ford Health, Detroit, MI, USA
| | - Jon J P Warner
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston Shoulder Institute, Boston, MA, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Okike K. My Grandmother's Knees: A Call for Research on Strategies to Address Racial and Ethnic Disparities in Orthopaedic Surgery. J Bone Joint Surg Am 2021; 103:1961-1962. [PMID: 34730562 DOI: 10.2106/jbjs.21.01081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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