Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures

Health Disparities in Patients With Musculoskeletal Injuries: Food Insecurity Is a Common and Clinically Challenging Problem

BACKGROUND

Health disparities have important effects on orthopaedic patient populations. Socioeconomic factors and poor nutrition have been shown to be associated with an increased risk of complications such as infection in patients undergoing orthopaedic surgery. Currently, there are limited published data on how food insecurity is associated with medical and surgical complications.

QUESTIONS/PURPOSES

We sought to (1) determine the percentage of patients who experience food insecurity in an orthopaedic trauma clinic at a large Level 1 trauma center, (2) identify demographic and clinical factors associated with food insecurity, and (3) identify whether there are differences in the risk of complications and reoperations between patients who experience food insecurity and patients who are food-secure.

METHODS

This was a cross-sectional study using food insecurity screening surveys, which were obtained at an orthopaedic trauma clinic at our Level 1 trauma center. All patients 18 years and older who were seen for an initial evaluation or follow-up for fracture care between November 2022 and February 2023 were considered for inclusion in this study. For inclusion in this study, the patient had to have surgical treatment of their fracture and have completed at least one food insecurity screening survey. Ninety-eight percent (121 of 123) of patients completed the screening survey during the study period. Data for 21 patients were excluded because of nonoperative treatment of their fracture, nonfracture-related care, impending metastatic fracture care, and patients who had treatment at an outside facility and were transferring their care. This led to a study group of 100 patients with orthopaedic trauma. The mean age was 51 years, and 51% (51 of 100) were men. The mean length of follow-up available for patients in the study was 13 months from the initial clinic visit. Patient demographics, hospital admission data, and outcome data were collected from the electronic medical records. Patients were divided into two cohorts: food-secure versus food-insecure. Patients were propensity score matched for adjusted analysis.

RESULTS

A total of 37% of the patients in this study (37 of 100) screened positive for food insecurity during the study period. Patients with food insecurity were more likely to have a higher BMI than patients with food security (32 kg/m 2 compared with 28 kg/m 2 ; p = 0.009), and they were more likely not to have healthcare insurance or to have Medicaid (62% [23 of 37] compared with 30% [19 of 63]; p = 0.003). After propensity matching for age, gender, ethnicity, current substance use, Charleston comorbidity index, employment status, open fracture, and length of stay, food insecurity was associated with a higher percentage of superficial infections (13% [4 of 31] compared with 0% [0 of 31]; p = 0.047). There were no differences between the groups in the risk of reoperation, deep infection, and nonunion.

CONCLUSION

Food insecurity is common among patients who have experienced orthopaedic trauma, and patients who have it may be at increased risk of superficial infections after surgery. Future research in this area should focus on defining these health disparities further and interventions that could address them.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Racial Disparities in Outcomes After Foot and Ankle Surgery: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis delved into the impact of race and ethnicity on outcomes following foot and ankle surgery, an area garnering increasing attention within the medical community. Despite significant literature on postsurgical clinical and functional outcomes, limited research has explored the influence of racial and ethnic factors on postoperative outcomes. In this study, data from 33 relevant studies, involving a total of 557,734 patients, were analyzed to assess outcomes across different racial and ethnic groups. Notably, only 6 studies met the criteria for inclusion in the final meta-analysis due to variations in outcome reporting. Findings revealed disparities in functional scores, pain levels, and resource utilization among different racial and ethnic cohorts. Specifically, non-White and minority patients exhibited higher rates of foot and ankle fractures and lower extremity surgeries, worse functional outcomes, increased pain, longer hospital stays, and a greater incidence of complications compared to their White counterparts. However, some studies presented contradictory results, emphasizing the necessity for further investigation to elucidate these discrepancies fully. This research underscores the importance of considering racial and ethnic factors in foot and ankle surgery outcomes and highlights the need for targeted interventions to address existing disparities.

Telehealth Potential in Pediatric Orthopaedics and Sports Medicine Care is Comparable to In-Person Care But Disparities Remain

BACKGROUND

Understanding the challenges and potential of telehealth visits (THVs) in a large population can inform future practice and policy discussion for pediatric orthopaedic and sports medicine (OSM) care. We comprehensively assess telehealth challenges and potential in a large pediatric OSM population based on access, visit completion, patient satisfaction, and technological challenges.

METHODS

Demographics, address, insurance, visit information, patient feedback, experience with video visits, and technical challenges of all 2019 to 2020 visits at our hospital were assessed (3,278,006 visits). We evaluated the differences in rate of telehealth utilization, rate of patient adherence, disparities in care access and patient satisfaction, and technological issues.

RESULTS

Compared with in-person prepandemic visits, THVs had lower ratios of non-White patients (by 5.8%; P <0.001), Hispanic patients (by 2.8%; P <0.001) and patients with public insurance (by 1.8%; P <0.001), and a higher mean distance between the patient's residence and clinic (by 18.8 miles; P <0.001). There were minimal differences in median household income (average $2297 less in THV; P <0.001) and social vulnerability index (average 0.01 points lower in THV; P <0.001) between groups. THVs had comparable patient satisfaction to in-person visits. Non-White patients, Hispanics, and those with public insurance had lower ratings for both in-person visits and THVs and had more technical difficulties during their THV.

CONCLUSIONS

Telehealth is a viable method of care for a range of pediatric OSM conditions, providing a similar quality of care as in-person visits with a greater geographic reach. However, in its current format, reduced disparities were not observed in pediatric OSM THVs.

LEVEL OF EVIDENCE

Level III.

Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients

Purpose

Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities.

Methods

The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period.

Results

Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients.

Conclusions

The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status.

Type of Study/Level of Evidence

Prognosis IV.

Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation

Objectives

To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery.

Design

Retrospective cohort study.

Setting

Mariner claims database.

Patients/Participants

Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study.

Intervention

Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing.

Main Outcome Measures

One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation.

Results

Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41).

Conclusions

Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population.

Level of Evidence

Prognostic Level III.

Transforming the Management of Articular Fractures in the Foot: A Critical Examination of Current Methods and Future Directions: A Review

This study provides a comprehensive examination of the current methodologies and potential strategies for the treatment of articular fractures of the foot. In the field of orthopedic healthcare, these fractures present a significant challenge due to their complex nature and the fact that they affect the routines of patients. The motivation behind this study is based on two main concepts. The first one is represented by the use of emerging medical technologies and personalized medicine to bring a significant transformation in the management of foot fractures and give a better quality of treatment that is accepted by the patient. However, because there are inequities in the availability of the necessary medical care and equipment, as well as uneven incorporation in clinical settings, new technologies cannot be used to treat these types of fractures. Regarding the second concept behind this study, it is indicated that although current treatment methods are essential, they have a number of shortcomings when it comes to properly addressing these types of injuries. An approach is needed that takes into account the biomechanical points of view and the particularities of each patient. This approach could be applied in all hospital settings. Through this study, we want to highlight the progress made in recent years in surgical techniques such as 3D printing, minimally invasive surgery (MIS), and biological products. However, in the application of this new discovery, new obstacles have been discovered that prevent the efficient treatment of these types of injuries. This study examines the effectiveness and limitations of current treatments, as well as how differences in healthcare, such as available equipment, training of medical staff, and technological advances, affect patient outcomes in everyday life. This research wishes to emphasize that continuous innovation, interdisciplinary collaboration, and the use of an optimal approach that is appropriate for each patient, are essential. This study aims to provide new insights and useful recommendations for future research and clinical practice. The main role of this research is to improve the quality of life of patients and increase the standards of care in this complex field, which is in permanent evolution.

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.].

Disparities Exist in the Experience of Financial Burden Among Orthopedic Trauma Patients: A Systematic Review

PURPOSE OF REVIEW

There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing.

RECENT FINDINGS

It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare.

Racial and Ethnic Disparities in Sports Medicine and the Importance of Diversity

Within orthopedics surgery as a specialty, sports medicine is one of the least diverse surgical subspecialties. Differences in minority representation between patient and provider populations are thought to contribute to disparities in care, access, and outcomes.

Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery

INTRODUCTION

Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention.

METHODS

We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery.

RESULTS

Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05.

CONCLUSIONS

For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Quality of antenatal care and outcomes of Hypertensive Disorders in Pregnancy among antenatal attendees: A comparison of urban and periurban health facilities in Ghana

Rural-urban-peri urban disparity assessments on health outcomes have been considered as critical determinants of health and health service outcomes. It is policy relevant in terms of the burden of disease and also provides focus on target interventions. This study aimed to assess the differences in the quality of Ante-natal Care (ANC) and the outcomes of Hypertensive Disorders in Pregnancy (HDPs) from selected health facilities in Ghana. This was a questionnaire-based cross-sectional study. Data on demographics, proportions of HDPs, quality of ANC and the outcomes of HDPs were collected. Logistic regression models were used to examine the association of the independent variables with the location of the health of facility. A total of 500 pregnant women were included in this study. There were 270 (54%) urban and 230 (46%) peri-urban dwellers. The proportion of HDPs varied with the location of the health facility. Women attending urban health facilities were more likely to be hypertensive (μ2 = 126.4; p<0.001), have chronic hypertension with superimposed pre-eclampsia (p< 0.001), have good quality ANC (μ2 = 41.28; p< 0.001), deliver full term (μ2 = 4.83; p = 0.028), and have excellent knowledge on HDPs (μ2 = 227.65; p< 0.001) compared to women receiving care in peri-urban health facilities. The method of delivery and outcome of birth did not statistically vary amongst the periurban and urban health facilities. There was an increase in the proportion in preterm in urban compared to periurban. The burden of HDPs was high in urban health facilities with high proportion of its mothers receiving quality ANC as well as having excellent knowledge on HDPs compared to mothers receiving care at the periurban health facilities. There is a need to target maternal care interventions to the periurban health facilities to improve obstetric health outcomes.

Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture

Importance

Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood.

Objective

To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF).

Design, Setting, and Participants

This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023.

Exposure

Eligibility for Medicare coverage at age 65 years.

Main Outcomes and Measures

Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years.

Results

A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage.

Conclusions and Relevance

Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.

Post-Trauma Discharge Instructions: Are We Dropping the Ball?

INTRODUCTION

Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors).

METHODS

We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05).

RESULTS

We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors.

CONCLUSION

Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures.

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed.

RESULTS

In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025).

CONCLUSIONS

Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis

Background

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis.

Methods

TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA.

Results

In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA.

Conclusion

Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis.

Level of Evidence

Level III, retrospective cohort study.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release

BACKGROUND

Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity.

METHODS

Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery.

RESULTS

The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively).

CONCLUSIONS

Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

In-Hospital Mortality Risk and Discharge Disposition Following Hip Fractures: An Analysis of the Texas Trauma Registry

Background

In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations.

Objective

Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures.

Methods

A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions.

Results

There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method.

Conclusion

Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.

Income and Insurance Status Impact Access to Health Care for Hip Osteoarthritis

Purpose

To explore differences in the affordability of and accessibility to health care among adults with hip osteoarthritis with respect to race/ethnicity, income, and insurance status.

Methods

This cross-sectional retrospective study was conducted using 2016 National Health Interview Survey (NHIS) data. NHIS data collection occurred continuously from January to December 2016. Individuals belonging to households and noninstitutionalized groups were included in the study. Because NHIS randomized surveys are conducted face-to-face on an annual basis, follow-up data are not collected.

Results

Answers from 38,158,634 weighted respondents with a mean age of 58.33 ± 0.33 years were assessed. Among adults with hip osteoarthritis, those with public insurance had increased odds of delaying care owing to lack of transportation and had decreased odds of delaying care and follow-up care owing to cost. Individuals who were uninsured or who belonged to lower income brackets were associated with increased odds of being unable to afford or utilize health care.

Conclusions

In this study, we found that income bracket and insurance status affect the accessibility to health care among adults with hip osteoarthritis in the United States.

Level of Evidence

Level IV, prognostic case series.

Provider Referral Patterns and Surgical Utilization Among New Patients Seen in Spine Clinic

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery.

SUMMARY OF BACKGROUND DATA

Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste.

MATERIALS AND METHODS

All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery.

RESULTS

From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04-1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002-1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011-1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177-1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085-1.302, P =0.0002).

CONCLUSIONS

A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals.

Health Inequities in Orthopaedic Trauma Surgery in the United States: A Scoping Review

BACKGROUND

Health inequities have been shown to have negative effects on patient care and the healthcare system. It is important for orthopaedic trauma surgeons and researchers to understand the extent to which patients are affected by these inequities.

METHODS

We conducted a scoping review as outlined by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. We searched PubMed and Ovid Embase for articles relating to orthopaedic trauma surgery and health inequities.

RESULTS

After exclusion criteria were applied, our final sample consisted of 52 studies. The most frequently evaluated inequities were sex (43 of 52 [82.7]), race/ethnicity (23 of 52 [44.2]), and income status (17 of 52 [32.7]). The least frequently evaluated inequities were lesbian, gay, bisexual, transgender, and queer identity (0 of 52 [0.0]) and occupational status (8 of 52 [15.4]). Other inequities evaluated included rural/underresourced (11 of 52 [21.1]) and educational level (10 of 52 [19.2]). No trend was observed when examining inequities reported by year.

CONCLUSION

Health inequities exist in orthopaedic trauma literature. Our study highlights multiple inequities in the field that need further investigation. Understanding current inequities and how to best mitigate them could improve patient care and outcomes in orthopaedic trauma surgery.

Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population

OBJECTIVE

To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population.

METHODS

This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury.

RESULTS

Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single.

CONCLUSIONS

In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.

Inclusive Mentorship and Sponsorship

Mentorship and sponsorship are part of academia because they are vital for professional and personal development. Inclusive mentorship is defined as mentoring across differences. It highlights the need of all mentors to be well-versed culturally and to recognize and circumvent bias and microaggressions. Inclusive mentorship can also elevate underrepresented populations in medicine and create intercultural relationships that also benefit the relationships we have with our diversifying patient populations. There are still several barriers prohibiting inclusive mentorship from being widely understood and employed. This article discusses the importance of and techniques for improving inclusive mentorship.

Patient Disparities and Provider Diversity in Orthopaedic Surgery: A Complex Relationship

Disparities in the access to, utilization of, and outcomes after orthopaedic surgery are a notable problem in the field that limits patients' ability to access the highest level of care and achieve optimal outcomes. Disparities exist based on numerous sociodemographic factors, with sex and race/ethnicity being two of the most well-studied factors linked to disparities in orthopaedic care. These disparities cross all subspecialties and tend to negatively affect women and racial/ethnic minorities. The increased recognition of the disparities in orthopaedic care has been paralleled by an increased recognition of the lack of diversity among orthopaedic surgeons. Although efforts are being made to improve the representation of women and underrepresented minorities among orthopaedic surgeons, the numbers, particularly of racial and ethnic minorities, show little improvement. The lack of gender and racial diversity among orthopaedic surgeons may be one of many factors related to the gender and racial disparities seen in orthopaedic care. Patients may prefer a provider that they can better identify with and that may affect care. Orthopaedic surgery as a specialty must continue to work to foster an inclusive environment and make concerted efforts to improve diversity through the recruitment of women and underrepresented minorities, among others, for the benefit of patients, surgeons, and the continued growth of the field as a whole.

Do heel-unloading orthoses improve clinical outcomes in patients after surgical treatment of calcaneal fracture? A propensity-matched, multicenter analysis of the TRON database

BACKGROUND

Postoperative protocols after surgical treatment of calcaneal fracture have not been standardized to date. There are only a few reports on the efficacy of heel-unloading orthoses (HUOs; Mars shoe, Graffin orthosis), and thier efficacy is uncertain.

OBJECTIVES

The purpose of this study was to compare postoperative radiologic and clinical outcomes in patients with calcaneal fractures who used Graffin orthosis.

STUDY DESIGN

Multicenter retrospective study.

METHODS

We finally extracted 182 patients from a database of the Trauma Research Group of Nagoya and divided them into two groups: group C (underwent casting or splinting only) and group O (Graffin orthosis was used). A propensity score algorithm was used to match group C to group O in a 1:1 ratio. We evaluated American Orthopaedic Foot and Ankle Society (AOFAS) score at three and six months after surgery and at final follow-up. Differences in reduction of the Böhler angle between the two groups were evaluated radiographically. All data were analyzed with a t-test or Fisher's exact test. P < .05 was considered statistically significant.

RESULTS

The AOFAS score 3 months after surgery in group O was significantly higher than that in group C (69.57 vs. 77.22; P = .004). However, there were no statistically significant differences between group C vs. group O in AOFAS scores at 6 months after surgery and at final follow-up (81.92 vs. 85.67 and 89.18 vs. 88.13; P = .087 and 0.597, respectively). There was no significant statistical difference in the reduction of the Böhler angle (5.07 vs. 5.89; P = .529).

CONCLUSIONS

At 3 months postoperatively, the orthosis group showed predominantly better functional results. We believe that heel-unloading orthoses are useful for patients who require an early return to work and to daily life.

Bucket-Handle Meniscus Tear Management With Meniscectomy Versus Repair Correlates With Patient, Socioeconomic, and Hospital Factors

INTRODUCTION

Bucket-handle meniscus tears are common knee injuries that are often treated surgically with meniscectomy or meniscal repair. Although clinical factors may influence the choice of one treatment approach over the other, the influence of patient, socioeconomic, and hospital factors remains poorly characterized. This study aimed to estimate the relative nationwide utilization of these two procedures and delineate a variety of factors that are associated with the selection of one treatment approach over the other.

METHODS

Meniscal repair and meniscectomy procedures conducted for isolated bucket-handle meniscus tears in 2016 and 2017 were identified in the Nationwide Ambulatory Surgery Sample database. Cases were weighted using nationally representative discharge weights. Univariate analyses and a multivariable logistic regression model were used to compare patient, socioeconomic, and hospital factors associated with meniscal repair versus meniscectomy.

RESULTS

In total, 12,239 cases were identified, which represented 17,236 cases after weighting. Of these, meniscal repair was conducted for 4,138 (24.0%). Based on the logistic regression model, meniscal repair was less likely for older and sicker patients. By contrast, several factors were associated with markedly higher odds of undergoing meniscal repair compared with meniscectomy. These included urban teaching hospitals; geographic location in the midwest, south, and west; and higher median household income.

DISCUSSION

Using a large nationally representative cohort, the current data revealed that only 24.0% of surgically treated bucket-handle meniscus tears were treated using repair. Identification of patient, socioeconomic, and hospital factors differentially associated with meniscal repair suggest that other factors may systematically influence surgical decision-making for this patient population. Surgeons should be conscious of these potential healthcare disparities when determining the optimal treatment for their patients.

LEVEL OF EVIDENCE

Level III.

Disparities in Telemedicine Utilization During COVID-19 Pandemic: Analysis of Demographic Data from a Large Academic Orthopaedic Practice

The coronavirus-19 (COVID-19) pandemic has prompted a shift in health-care provision toward implementation of telemedicine. This study investigated demographic information on orthopaedic telemedicine utilization at a single academic orthopaedic institution in an effort to identify factors associated with telemedicine usage.

Racial Differences in Orthopedic Trauma Surgery

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

The Influence of Health Equity on Patient Outcomes in Orthopaedics

Health equity has become both a national and international health priority when addressing health disparities that influence health outcomes across all patient populations. Orthopaedic nurses play a critical role in advancing health equity among orthopaedic patients when it comes to ensuring orthopaedic patients have fair and just opportunities to achieve their best state of musculoskeletal health. For health equity to be realized by the specialty of orthopaedics and the orthopaedic patient populations being served, it is important for the orthopaedic nurse to be involved in community-based partnerships, research opportunities, and health policy initiatives that focus on the advancement of health equity for all populations.

Differences and their contexts between teaching and nonteaching hospitals in Iran with other countries: A concurrent mixed-methods study

BACKGROUND

In terms of missions, hospitals are divided into teaching and nonteaching. In addition, differences in health-care systems in countries will lead to differences in hospitals' operation. Iran, as a specific health-care system, is different from other countries. Hence, the present study investigated differences between teaching and nonteaching hospitals and their differences in Iran and the world.

MATERIALS AND METHODS

A concurrent mixed-methods study was conducted in two stages. The first stage was a narrative review of studies (2000-2020). Using narrative inquiry and reflective analysis, the content was analyzed and the categories were extracted. The second stage was a qualitative study conducted using semi-structured interviews with forty Iranian hospital managers and policymakers through a purposive sampling in 2020. Content analysis was made using deductive approach, and MAXQDA 12 was used for data analysis.

RESULTS

According to the first stage, categories were extracted as follows: service quality, type of cases, patient satisfaction, efficiency, performance indicators, patient safety, personnel, use of drugs, access to services, technologies, justice in the type of services received, using guidelines, processes, and number of services. In the second stage, 8 main categories, 17 categories, and 45 subcategories were extracted. The extracted main categories were as follows: mission and target, management and behavioral organizations, supply chain and chain of results, human resources, costs and budget, policy demands, clients' satisfaction and patients' right, and integration of medical education.

CONCLUSION

Unlike other countries, in Iran, the combination of missions and the complete dependence of teaching hospitals on the government has caused differences. Reducing the treatment mission of teaching hospitals; differences in the budget and development of its indicators; lower tariffs for teaching hospitals; developing a cost-income management model and supply chain; preventing uncertainty other than medical students except medicine; considering the clients' right to choose hospital; and organizing research missions in hospitals were the solutions for decrease differences.

Racial and Gender Shoulder Arthroplasty Utilization Disparities of High- and Low-Volume Centers in New York State

Introduction

The literature has consistently demonstrated utilization disparities in joint replacement procedures, though no studies have evaluated disparities in total shoulder arthroplasty with regard to operative volume.

Methods

We queried the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database for 32 410 total shoulder arthroplasties performed between 2009 and 2017. Patients were identified using Clinical Classifications Software code 154 for Non-Hip/Knee Arthroplasty and All Patient Refined-Diagnosis Related Group code 322 for Shoulder. Racial groups included Hispanic, non-Hispanic white, non-Hispanic black, and Other. High-volume centers were facilities that performed 2 standard deviations above the mean annual procedures. Utilization rates were calculated by dividing total shoulder arthroplasties per group by the 2010 NY Census population of that group. The Fisher exact test was used to determine significance.

Results

Total shoulder arthroplasty utilization increased from 43/100 000 to 73/100 000, two-thirds of which was driven by an increase in white resident utilization. More White residents per 100 000 underwent shoulder arthroplasty than Black, Hispanic, and Other residents per 100 000 residents of their respective race. White residents were 90% more likely than Hispanic residents to undergo total shoulder arthroplasty at high-volume centers (P = .04). There were no differences in utilization rate regarding operative volume comparing Black or Other residents to White residents. More females underwent total shoulder arthroplasty than males, though there was no difference in utilization rate regarding operative volume.

Conclusion

Though total shoulder arthroplasty utilization nearly doubled, disparities persisted across gender and minority groups particularly in Hispanic utilization as White residents were 90% more likely than Hispanic residents to undergo shoulder arthroplasty at high-volume centers.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center

Objectives:

Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic.

Design:

Retrospective chart review.

Setting:

Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic.

Intervention:

Virtual visits utilizing the Doxy.me platform.

Main Outcome Measures:

Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Methods:

All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Results:

Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028).

Conclusion:

A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.