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Khatri C, Ahmed I, Dhaif F, Rodrigues J, Underwood M, Davis ET, Mitchell P, Metcalfe A. What's important for recovery after a total knee replacement? A systematic review of mixed methods studies. Arch Orthop Trauma Surg 2024; 144:2213-2221. [PMID: 38070014 PMCID: PMC11093842 DOI: 10.1007/s00402-023-05136-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/11/2023] [Indexed: 04/21/2024]
Abstract
BACKGROUND Understanding how patients perceive and prioritise various aspects of recovery following total knee replacement, including pain, function and return to activity, will help clinicians in pre-operative consultations by ensuring they effectively address patient concerns and managing their expectations. AIMS The aim of this study is to identify aspects of recovery that are important to people after a total knee replacement. METHODS Studies were identified from Medline, Embase, PsycInfo, Cochrane Library and Web of Science. This mixed methods review included all original study types (quantitative, qualitative, discrete choice experiments and mixed methods design). Reviews and non-peer-reviewed publications were excluded. Studies with participants (age ≥ 18 years) who had a primary TKR for osteoarthritis were included. Studies of people with unicompartmental knee, patella-femoral or revision knee replacement were excluded. Recovery attributes were extracted from individual papers and grouped into recovery themes. RESULTS A total of 23 studies with 8404 participants and 18 recovery themes were developed. The most frequently identified overarching theme was pain, followed by activities of daily living, mobility (walking), recreational activities, specific functional movements of the knee, use of walking aids, sexual activity and range of motion of the knee. Medical complications were an infrequently reported theme, however, was deemed to be high importance. CONCLUSIONS Reducing pain, returning of activities and daily living and mobility are the three most frequently reported recovery domains for people after TKR. Clinicians should be aware of recovery themes, to ensure they are explored sufficiently when consenting for a TKR. Future research should aim to determine the relative importance of these attributes compared to each other. Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021253699.
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Affiliation(s)
- Chetan Khatri
- Clinical Trials Unit, University of Warwick, Coventry, UK.
- Clinical Sciences Research Laboratories, University Hospitals Coventry & Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Imran Ahmed
- Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Fatema Dhaif
- Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | - Edward T Davis
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Paul Mitchell
- Health Economics Bristol, Population Health Sciences, University of Bristol, Bristol, UK
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Peterman NJ, Pagani N, Mann R, Li RL, Gasienica J, Naik A, Sun D. Disparities in Access to Robotic Knee Arthroplasty: A Geospatial Analysis. J Arthroplasty 2024; 39:864-870. [PMID: 37852446 DOI: 10.1016/j.arth.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The utilization of robotic knee arthroplasty (RKA) continues to increase across the United States. The aim of this geospatial analysis was to elucidate if RKA is distributed uniformly across the United States or if disparities exist in patient access. METHODS Publicly available provider-finding functions for 5 major manufacturers of RKA systems were used to obtain the practice locations of surgeons performing RKA along with their associated RKA system manufacturer. The average travel distance for each county to the nearest RKA surgeon was calculated and Moran's index clustering analysis was used to find hotspots and coldspots of RKA access. A logistic regression model was used to identify the predictive odds ratios between robotic hotspots and coldspots with county-level sociodemographic variables. Of the 34,216 currently practicing orthopedic surgeons in 2022, 2,571 have access to robotic assistance for knee arthroplasty. RESULTS Hotspots of increased travel time were predominantly in West South Central and West North Central census regions. Hotspots were significantly more rural and consisted of predominantly White populations, with lower median income and health insurance coverage. CONCLUSIONS The results of the current study align with existing literature, demonstrating absolute geographic access disparities for rural and economically disadvantaged populations. Additionally, relative access disparities persist for minority populations and individuals with high comorbidity burdens residing in urban areas.
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Affiliation(s)
- Nicholas J Peterman
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Nicholas Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Rachel Mann
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Richard L Li
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Jacob Gasienica
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Daniel Sun
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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Adu Y, Hurley J, Ring D. Are There Racial and Ethnic Variations in Patient Attitudes Toward Hip and Knee Arthroplasty for Osteoarthritis? A Systematic Review. Clin Orthop Relat Res 2024:00003086-990000000-01507. [PMID: 38393955 DOI: 10.1097/corr.0000000000003021] [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: 09/30/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND It is not clear why people who identify as Black or Hispanic are less likely to undergo discretionary musculoskeletal surgery such as arthroplasty for osteoarthritis of the hip or knee. Inequities and mistrust are important factors to consider. The role of socioeconomic factors and variation in values, attitudes, and beliefs regarding discretionary procedures are less well understood. A systematic review of the evidence regarding mindsets toward knee and hip arthroplasty among Black and Hispanic people could inform attempts to limit disparities in care. QUESTIONS/PURPOSES In a systematic review of qualitative and quantitative evidence, we asked: (1) What factors are associated with racial and ethnic variations in attitudes toward discretionary hip and knee arthroplasty for osteoarthritis? (2) Do studies that investigate racial and ethnic variations in mindsets toward discretionary orthopaedic care control for potential confounding by socioeconomic factors? METHODS A systematic search of PubMed, Cochrane, and Embase (last searched August 2023) for studies that addressed racial and ethnic variations in mindsets toward discretionary musculoskeletal care use was conducted. We excluded studies that were not published in English, lacked full-text availability, and those that documented patient approaches without comparing them to the willingness to undergo a discretionary procedure. Twenty-one studies were included-14 quantitative and seven qualitative-including 8472 patients. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. The studies included demonstrated low risk of bias: five quantitative studies lacked detail regarding nonresponse bias and one qualitative study lacked details regarding the racial and ethnic composition of its cohort. To answer our first research question, we categorized themes associated with racial differences in mindsets toward discretionary care and recorded the presence of associations in quantitative studies. To answer our second question, we identified whether quantitative studies address potential confounding with socioeconomic factors. There were no randomized trials, so no meta-analysis was performed. RESULTS In general, self-identified Black and Hispanic patients had a lower preference for hip and knee arthroplasty than self-identified White patients. Black patients were more likely to regard osteoarthritis as a natural and irremediable part of aging and prefer home remedies. Both Black and Hispanic patients valued support from religion and were relatively cost-conscious. Black and Hispanic patients had lower perception of benefit, were less familiar with the procedure, had higher levels of fear regarding surgery and recovery, and had more-limited trust in care. Generally, Black and Hispanic social networks tended to address these concerns, whereas White social networks were more likely to discuss the benefits of surgery. Thirteen of 14 quantitative studies considered and accounted for potential confounding socioeconomic variables in their analyses. CONCLUSION The observation that lower preference for discretionary arthroplasty among Black and Hispanic patients is independent from socioeconomic factors and is related to accommodation of aging, preference for agency (home remedies), greater consideration of costs, recovery concerns, and potential harms directs orthopaedic surgeons to find ways to balance equitable access to specialty care and discretionary surgery while avoiding undermining effective accommodation strategies. It is important not to assume that lower use of discretionary surgery represents poorer care or is a surrogate marker for discrimination. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Yaw Adu
- School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Jack Hurley
- School of Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - David Ring
- Department of Orthopaedic Surgery, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Barry K, Mekkawy KL, Nayar SK, Oni JK. Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database. J Am Acad Orthop Surg 2023; 31:e788-e797. [PMID: 37205876 DOI: 10.5435/jaaos-d-22-00803] [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: 12/08/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups. METHODS This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates. RESULTS Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites. CONCLUSION There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Kawsu Barry
- From the From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Barry, Dr. Mekkawy, and Dr. Oni), and the From the Department of Orthopedic Surgery (Dr. Nayar), Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Ling K, Leatherwood W, Fassler R, Burgan J, Komatsu DE, Wang ED. Disparities in postoperative total shoulder arthroplasty outcomes between Black and White patients. JSES Int 2023; 7:842-847. [PMID: 37719829 PMCID: PMC10499855 DOI: 10.1016/j.jseint.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Despite the rise in surgical volume for total shoulder arthroplasty (TSA) procedures, racial disparities exist in outcomes between White and Black populations. The purpose of this study was to compare 30-day postoperative complication rates between Black and White patients following TSA. Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent TSA between 2015 and 2019. Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between Black or African American race and postoperative complications. Results A total of 19,733 patients were included in the analysis, 18,669 (94.6%) patients in the White cohort and 1064 (5.4%) patients in the Black or African American cohort. Demographics and comorbidities that were significantly associated with Black or African American race were age 40-64 years (P < .001), body mass index ≥40 (P < .001), female gender (P < .001), American Society of Anesthesiologists classification ≥3 (P < .001), smoking status (P < .001), non-insulin and insulin dependent diabetes mellitus (P < .001), hypertension requiring medication (P < .001), disseminated cancer (P = .040), and operative duration ≥129 minutes (P = .002). Multivariate logistic regression identified Black or African American race to be independently associated with higher rates of readmission (odds ratio: 1.42, 95% confidence interval: 1.05-1.94; P = .025). Conclusion Black or African American race was independently associated with higher rates of 30-day readmission following TSA.
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Affiliation(s)
- Kenny Ling
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | | | - Richelle Fassler
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Jane Burgan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
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Rajamohan HR, Wang T, Leung K, Chang G, Cho K, Kijowski R, Deniz CM. Prediction of total knee replacement using deep learning analysis of knee MRI. Sci Rep 2023; 13:6922. [PMID: 37117260 PMCID: PMC10147603 DOI: 10.1038/s41598-023-33934-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
Current methods for assessing knee osteoarthritis (OA) do not provide comprehensive information to make robust and accurate outcome predictions. Deep learning (DL) risk assessment models were developed to predict the progression of knee OA to total knee replacement (TKR) over a 108-month follow-up period using baseline knee MRI. Participants of our retrospective study consisted of 353 case-control pairs of subjects from the Osteoarthritis Initiative with and without TKR over a 108-month follow-up period matched according to age, sex, ethnicity, and body mass index. A traditional risk assessment model was created to predict TKR using baseline clinical risk factors. DL models were created to predict TKR using baseline knee radiographs and MRI. All DL models had significantly higher (p < 0.001) AUCs than the traditional model. The MRI and radiograph ensemble model and MRI ensemble model (where TKR risk predicted by several contrast-specific DL models were averaged to get the ensemble TKR risk prediction) had the highest AUCs of 0.90 (80% sensitivity and 85% specificity) and 0.89 (79% sensitivity and 86% specificity), respectively, which were significantly higher (p < 0.05) than the AUCs of the radiograph and multiple MRI models (where the DL models were trained to predict TKR risk using single contrast or 2 contrasts together as input). DL models using baseline MRI had a higher diagnostic performance for predicting TKR than a traditional model using baseline clinical risk factors and a DL model using baseline knee radiographs.
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Affiliation(s)
| | - Tianyu Wang
- Center for Data Science, New York University, 60 5th Ave, New York, NY, 10011, USA
| | - Kevin Leung
- Courant Institute of Mathematical Sciences, New York University, 251 Mercer St, New York, NY, 10012, USA
| | - Gregory Chang
- Department of Radiology, New York University Langone Health, 660 1st Ave, New York, NY, 10016, USA
| | - Kyunghyun Cho
- Center for Data Science, New York University, 60 5th Ave, New York, NY, 10011, USA
- Courant Institute of Mathematical Sciences, New York University, 251 Mercer St, New York, NY, 10012, USA
| | - Richard Kijowski
- Department of Radiology, New York University Langone Health, 660 1st Ave, New York, NY, 10016, USA
| | - Cem M Deniz
- Department of Radiology, New York University Langone Health, 660 1st Ave, New York, NY, 10016, USA.
- Bernard and Irene Schwartz Center for Biomedical Imaging, New York University Langone Health, 650 First Avenue, Room 418, New York, NY, 10016, USA.
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MacMahon AS, Mekkawy KL, Barry K, Khanuja HS. Racial and Ethnic Disparities in Short-Stay Total Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(22)01134-2. [PMID: 36623611 DOI: 10.1016/j.arth.2022.12.044] [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: 08/27/2022] [Revised: 12/13/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The purpose of this study was to understand racial and ethnic disparities in hospital-based, Medicare-defined outpatient total knee arthroplasty (TKA). We aimed to determine the following: 1) whether there are differences in preoperative characteristics or postoperative outcomes in outpatient TKA between racial/ethnic groups and 2) trends in outpatient TKA volume, based on race/ethnicity. METHODS This was a retrospective cohort study of a large national database. Outpatient TKAs performed between 2012 and 2018 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were compared between White, Black, Asian, and Hispanic patients. RESULTS Of 54,183 outpatient patients, 85.6% were White, 7.4% Black, 2.6% Asian, and 4.1% Hispanic. Black patients had the highest body mass index, and there were higher rates of diabetes among all minority groups (P < .001). All minority groups were more likely to be discharged to a rehabilitation or a skilled care facility compared to White patients (P < .001). Annual percentage increases in outpatient TKA were most pronounced for Asians and Hispanics and least pronounced among Blacks, when compared to White patients. CONCLUSION The outcomes of outpatient TKA are impacted by risk factors that reflect underlying disparities in healthcare. As joint arthroplasties have come off the inpatient-only list and procedures move to ambulatory settings, these disparities will likely magnify and impact outcomes, costs, and access points. Extensive preoperative optimization and interventions that target medical and social factors may help to reduce these disparities in TKA and increase access among minority patients. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Aoife S MacMahon
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kevin L Mekkawy
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kawsu Barry
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hwang A, Zhang L, Ramirez G, Maloney M, Voloshin I, Thirukumaran C. Black Race, Hispanic Ethnicity, and Medicaid Insurance Are Associated With Lower Rates of Rotator Cuff Repair in New York State. Arthroscopy 2022; 38:3001-3010.e2. [PMID: 35817374 DOI: 10.1016/j.arthro.2022.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair. METHODS A retrospective review of the Statewide Planning and Research Cooperative System Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months of follow-up. Bivariate analysis using χ2 tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair. RESULTS A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (adjusted odds ratio [aOR] 0.78; 95% confidence interval [CI] 0.69-0.87; P < .001), Hispanic/Latino ethnicity (aOR 0.91; 95% CI 0.85-0.97); P = .004), and Medicaid (aOR 0.75; 95% CI 0.70-0.80; P < .001), or other government insurance (aOR 0.82; 95% CI 0.78-0.86; P < .001) were independently associated with lower rates of rotator cuff repair. Male sex (aOR 1.18; 95% CI 1.14-1.22; P < .001), Asian race (aOR 1.27; 95% CI 1.00-1.62; P = .048), workers' compensation insurance (aOR 1.12; 95% CI 1.07-1.18; P < .001), and greater home ZIP code income quartile (aOR 1.19; 95% CI 1.09-1.30; P < .001) were independently associated with greater rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology. CONCLUSIONS In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017 to 2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home ZIP code income quartile. CLINICAL RELEVANCE This study reports disparities in the use of rotator cuff repair for individuals with rotator cuff pathology.
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Affiliation(s)
- Alan Hwang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A..
| | - Linda Zhang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Gabriel Ramirez
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael Maloney
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Ilya Voloshin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Caroline Thirukumaran
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Association Between Race/Ethnicity and Total Joint Arthroplasty Utilization in a Universally Insured Population. J Am Acad Orthop Surg 2022; 30:e1348-e1357. [PMID: 36044283 DOI: 10.5435/jaaos-d-22-00146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Previous studies have documented racial and ethnic disparities in total joint arthroplasty (TJA) utilization in the United States. A potential mediator of healthcare disparities is unequal access to care, and studies have suggested that disparities may be ameliorated in systems of universal access. The purpose of this study was to assess whether racial/ethnic disparities in TJA utilization persist in a universally insured population of patients enrolled in a managed healthcare system. METHODS This retrospective cohort study used data from a US integrated healthcare system (2015 to 2019). Patients aged 50 years and older with a diagnosis of hip or knee osteoarthritis were included. The outcome of interest was utilization of primary total hip arthroplasty and/or total knee arthroplasty, and the exposure of interest was race/ethnicity. Incidence rate ratios (IRRs) were modeled using multivariable Poisson regression controlling for confounders. RESULTS There were 99,548 patients in the hip analysis and 290,324 in the knee analysis. Overall, 10.2% of the patients were Black, 20.5% were Hispanic, 9.6% were Asian, and 59.7% were White. In the multivariable analysis, utilization of primary total hip arthroplasty was significantly lower for all minority groups including Black (IRR, 0.55, 95% confidence interval [CI], 0.52-0.57, P < 0.0001), Hispanic (IRR, 0.63, 95% CI, 0.60-0.66, P < 0.0001), and Asian (IRR, 0.64, 95% CI, 0.61-0.68, P < 0.0001). Similarly, utilization of primary total knee arthroplasty was significantly lower for all minority groups including Black (IRR, 0.52, 95% CI, 0.49-0.54, P < 0.0001), Hispanic (IRR, 0.72, 95% CI, 0.70-0.75, P < 0.0001), and Asian (IRR, 0.60, 95% CI, 0.57-0.63, P < 0.0001) (all in comparison with White as reference). CONCLUSIONS In this study of TJA utilization in a universally insured population of patients enrolled in a managed healthcare system, disparities on the basis of race and ethnicity persisted. Additional research is required to determine the reasons for this finding and to identify interventions which could ameliorate these disparities.
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Barbera JP, Raymond HE, Zubizarreta N, Poeran J, Chen DD, Hayden BL, Moucha CS. Racial Differences in Manipulation Under Anesthesia Rates Following Total Knee Arthroplasty. J Arthroplasty 2022; 37:1865-1869. [PMID: 35398226 DOI: 10.1016/j.arth.2022.03.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the extensive literature on racial disparities in care and outcomes after total knee arthroplasty (TKA), data on manipulation under anesthesia (MUA) is lacking. We aimed to determine (1) the relationship between race and rate of (and time to) MUA after TKA, and (2) annual trends in racial differences in MUA from 2013 to 2018. METHODS This retrospective cohort study (using 2013-2018 Medicare Limited Data Set claims data) included 836,054 primary TKA patients. The primary outcome was MUA <1 year after TKA; time from TKA to MUA in days was also recorded. A mixed-effects multivariable model measured the association between race (White, Black, Other) and odds of MUA. Odds ratios (OR) and 95% confidence intervals (CI) were reported. A Cochran Armitage Trend test was conducted to assess MUA trends over time, stratified by race. RESULTS MUA after TKA occurred in 1.7%, 3.2% and 2.1% of White, Black, and Other race categories, respectively (SMD = 0.07). After adjustment for covariates, (Black vs White) patients had increased odds of requiring an MUA after TKA: odds ratio (OR) 1.97, 95% confidence intervals (CI) 1.86-2.10, P < .0001. Moreover, White (compared to Black) patients had significantly shorter time to MUA after TKA: 60 days (interquartile range [IQR] 46-88) versus 64 days (interquartile range [IQR] 47-96); P < .0001. These disparities persisted from 2013 through 2018. CONCLUSION Continued racial differences exist for rates and timing of MUA following TKA signifying the continued need for efforts aimed toward understanding and eliminating inequalities that exist in total joint arthroplasty (TJA) care.
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Affiliation(s)
- Joseph P Barbera
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Hayley E Raymond
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Nicole Zubizarreta
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Jashvant Poeran
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Darwin D Chen
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
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Cohen-Levy WB, Lans J, Salimy MS, Melnic CM, Bedair HS. The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty. J Arthroplasty 2022; 37:S428-S433. [PMID: 35307241 DOI: 10.1016/j.arth.2022.02.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. METHODS We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. RESULTS Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. CONCLUSION Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.
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Affiliation(s)
- Wayne B Cohen-Levy
- Department of Orthopaedic Surgery, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Orthopaedic Surgery, University Hospitals/Cleveland Medical Center, Cleveland, Ohio
| | - Jonathan Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mehdi S Salimy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Newton-Wellesley Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Almaawi A, Aloud W, Alshayhan F, Aljedia K, Alaskar F, Alsuleiman O. Awareness about total knee replacement among Saudi population. J Family Med Prim Care 2022; 11:1308-1313. [PMID: 35516661 PMCID: PMC9067221 DOI: 10.4103/jfmpc.jfmpc_1437_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/11/2021] [Accepted: 10/16/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction The purpose of this study is to identify the knowledge of the general population about knee osteoarthritis and its surgical interventions in the management of knee osteoarthritis. Knee osteoarthritis is a prevalent disease. A lack of knowledge about the nature of the disease may delay seeking medical advice until the advanced stage of the disease. Methods This cross-sectional study was conducted among 486 participants (≥18 years) who were sampled randomly from an osteoarthritis awareness campaign located within a shopping facility located in Riyadh in 2020. Data were collected via a structured questionnaire, which included six domains; demographic information, causes, symptoms, treatment, complications, and general questions. Data for this study were analyzed by using the Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. The t-test and one-way Analysis of Variance (ANOVA) were used for continuous variables. Univariate and multivariate logistic regression were used to assess the associated factors with a low level of knowledge. A P value of <0.05 was considered statistically significant. Results Most of the participants in our study were males (56.8%) and Saudi nationals (89.7%). (83.74%). Consider that surgical intervention is the best treatment when non-surgical options do not work. The mean questionnaire score for the 486 participants was found to be 20.85 ± 5.29 out of 35 points. In comparing the male to female total scores, we found the mean female total score to be statistically significant and higher than that of the males with a P value of 0.036. Furthermore, we found that the non-Saudis had a total score higher than the Saudis with a P value of 0.016. On the other hand, the difference in the total scores between the city and rural area residents and different educational levels were statistically insignificant. Conclusions Our results demonstrate that the majority of the community has satisfactory awareness about the treatment options of knee osteoarthritis. It also demonstrates the domains that require more effort for increased public awareness of knee osteoarthritis.
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Affiliation(s)
- Abdulaziz Almaawi
- Department of Orthopedic Surgery and College of Medicine, Riyadh, Saudi Arabia
| | - Wael Aloud
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alshayhan
- Department of Orthopedic Surgery and College of Medicine, Riyadh, Saudi Arabia
| | - Khaled Aljedia
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alaskar
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Omar Alsuleiman
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
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13
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Alvarez PM, McKeon JF, Spitzer AI, Krueger CA, Pigott M, Li M, Vajapey SP. Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities. JBJS Rev 2022; 10:01874474-202203000-00003. [PMID: 35231001 DOI: 10.2106/jbjs.rvw.21.00161] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paul M Alvarez
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John F McKeon
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew I Spitzer
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Matthew Pigott
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mengnai Li
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sravya P Vajapey
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Abstract
The United States healthcare system underperforms in healthcare access, quality, and cost resulting in some of the poorest health outcomes among comparable countries, despite spending more of its gross national product on healthcare than any other country in the world. Within the United States, there are significant healthcare disparities based on race, ethnicity, socioeconomic status, education level, sexual orientation, gender identity, and geographic location. COVID-19 has illuminated the racial disparities in health outcomes. This article provides an overview of some of the main concepts related to health disparities generally, and in orthopaedics specifically. It provides an introduction to health equity terminology, issues of bias and equity, and potential interventions to achieve equity and social justice by addressing commonly asked questions and then introduces the reader to persistent orthopaedic health disparities specific to total hip and total knee arthroplasty.
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Affiliation(s)
- Susan Salmond
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
| | - Caroline Dorsen
- Susan Salmond, EdD, RN, ANEF, FAAN, School of Nursing, Rutgers University-The State University of New Jersey, Newark
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15
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Usiskin I, Misra D. Racial Disparities in Elective Total Joint Arthroplasty for Osteoarthritis. ACR Open Rheumatol 2022; 4:306-311. [PMID: 34989176 PMCID: PMC8992460 DOI: 10.1002/acr2.11399] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/27/2022] Open
Abstract
Total joint arthroplasty (TJA) is an effective elective surgical procedure for knee and hip osteoarthritis (OA), yet racial disparities in the use of and outcomes from TJA have been recognized. Racial minority individuals are less willing to undergo TJA, demonstrate worse surgical and functional outcomes, and are more likely to undergo surgery at a low‐procedure‐volume center. In this systematic review, we summarize evidence to date on racial disparities in TJA and discuss potential factors that may underlie this gap in care for patients with OA.
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Affiliation(s)
- Ilana Usiskin
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Devyani Misra
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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16
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Farley KX, Dawes AM, Wilson JM, Toston RJ, Hurt JT, Gottschalk MB, Navarro RA, Wagner ER. Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States. JB JS Open Access 2022; 7:JBJSOA-D-21-00144. [PMID: 35673617 PMCID: PMC9165742 DOI: 10.2106/jbjs.oa.21.00144] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities.
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Affiliation(s)
- Kevin X. Farley
- Department of Orthopaedic Surgery, Oakland University William Beaumont Orthopaedics, Royal Oaks, Michigan
| | - Alexander M. Dawes
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Jacob M. Wilson
- Division of Adult Reconstruction, Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Roy J. Toston
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - John T. Hurt
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Michael B. Gottschalk
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Ronald A. Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente, Pasadena, California
| | - Eric R. Wagner
- Division of Upper Extremity, Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
- Email for corresponding author:
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17
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Hurley VB. Are patients really getting what they want? The routine implementation of decision aids for patients with hip or knee osteoarthritis in the high value healthcare collaborative and alignment between patient treatment choice and receipt. J Eval Clin Pract 2021; 27:1207-1215. [PMID: 33829617 DOI: 10.1111/jep.13570] [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: 11/24/2020] [Revised: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Alignment between patients' treatment choices and treatments received is acknowledged as an important outcome of shared decision-making (SDM), yet recent research suggests that patients' choices do not always align with their actual treatment trajectories. This paper explores the alignment of patient-expressed treatment choices (for surgery or medical management) after exposure to decision aids and treatments received among patients with hip or knee osteoarthritis within High Value Healthcare Collaborative (HVHC) systems as the collaborative integrated decision aids intended to support SDM into routine clinical practice. METHOD This retrospective cohort study examines data from adult (≥18 years) patients with hip or knee osteoarthritis who received decision aids as part of orthopaedic consultations within HVHC systems between 2012 and 2015. Multivariable logistic regression explored the association between patient-level characteristics with the odds of treatment choice-receipt alignment. RESULTS The majority of patients with knee osteoarthritis (68.3%) and hip osteoarthritis (71.9%) received treatments aligned with their choices following exposure to decision aids, but analyses reveal important differences in the odds of such alignment across patient characteristics. In adjusted models, African American patients with knee osteoarthritis had 50% lower odds of receiving treatment aligned with their choices compared with Caucasian patients (OR = 0.52, P < .05). Medicare- or Medicaid-insured knee patients had 49% and 59% lower odds (respectively) of receiving choice-aligned treatments relative to privately insured patients. Patients with knee (OR = 0.40, P < .01) or hip (OR = 0.75, P < .05) osteoarthritis at earlier decision-making stages had lower odds of receiving treatments congruent with their choices. CONCLUSION This work elucidates the odds of treatment choice-aligned care for patients within health care systems attempting to routinely integrate decision aids to support SDM into clinical practice and underscores the gaps in achieving this alignment among African American patients, those with public insurance and those at early decision-making stages.
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Affiliation(s)
- Vanessa B Hurley
- Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
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18
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Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization. J Arthroplasty 2021; 36:3845-3849. [PMID: 34479764 DOI: 10.1016/j.arth.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/23/2021] [Accepted: 08/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Racial disparities surrounding the utilization of total hip and total knee arthroplasty (THA, TKA) are well documented. The Implicit Association Test (IAT) is a validated tool used to measure implicit and explicit bias. The purpose of this study is to evaluate if variations in IAT scores by geographical region in the United States (US) correspond with regional variations in THA and TKA utilization by blacks compared to whites. METHODS Data from the US Census and National Inpatient Sample from 2012 to 2014 were used to calculate THA and TKA utilization rates among Medicare-aged blacks and whites. Data were aggregated by US Census Bureau Division. Regional implicit bias was assessed by calculating a weighted average of IAT scores for each division. RESULTS Across all geographic regions and years, the surveyed population demonstrated an implicit bias favoring whites over blacks. The population adjusted ratio of white-to-black utilization of THA and TKA by geographic division varied between 0.86-1.85 and 0.87-2.01, respectively. The difference in utilization between geographic divisions reached statistical significance (P < .001). No correlation was found between the IAT scores and race-specific utilization ratios among geographic divisions. CONCLUSION Implicit bias as measured by regional IAT did not reflect THA and TKA utilization disparities. The racial disparity in utilization of THA and TKA significantly varied between divisions. The observed disparity was greater in divisions with a relatively higher proportion of blacks. To the authors' knowledge, this is the first study to evaluate the impact of implicit bias on utilization of THA and TKA.
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Chun DS, Leonard AK, Enchill Z, Suleiman LI. Racial Disparities in Total Joint Arthroplasty. Curr Rev Musculoskelet Med 2021; 14:434-440. [PMID: 34626322 PMCID: PMC8733080 DOI: 10.1007/s12178-021-09718-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The primary aim of this review was to evaluate recently published total joint arthroplasty (TJA) studies in order to accurately summarize the current concepts regarding racial and ethnic disparities in total joint arthroplasty. RECENT FINDINGS Many studies found that racial and ethnic disparities in TJA are present in all phases of arthroplasty care including access to, utilization of, and postoperative outcomes after TJA. Factors that limit patient access to TJA-increased patient comorbidities, lower socioeconomic status, and Medicaid/uninsured status-are also disproportionately associated with underrepresented patient populations. Minority patients are more likely to require more intensive postoperative rehabilitation and non-home discharge placement. This in turn potentially adds additional concerns regarding hospital/provider reimbursement in light of the current Medicare/Medicaid model for arthroplasty surgeons, thus creating a recurrent cycle in which disparities in TJA reflect the complex interplay of overall health disparities and access inequalities associated with racial and ethnic biases. Literature demonstrating evidenced-based interventions to minimize these disparities is sparse, but the multifactorial cause of disparities in TJA highlights the need for multifaceted solutions on both a systemic and individual level.
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Affiliation(s)
- Danielle S Chun
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Annemarie K Leonard
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Zenaida Enchill
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University, 259 E. Erie St. 13th Floor, Chicago, IL, 60611, USA.
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20
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Disparities across Diverse Populations in the Health and Treatment of Patients with Osteoarthritis. Healthcare (Basel) 2021; 9:healthcare9111421. [PMID: 34828468 PMCID: PMC8619799 DOI: 10.3390/healthcare9111421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
The study of disparities across diverse populations regarding the health and treatment of patients with osteoarthritis (OA) is recognized as a priority for investigation and action by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the American Academy of Orthopedic Surgeons (AAOS). OA is a common condition that increases with age, but with prevalence generally similar across racial and ethnic groups. However, disparities in the treatment of OA among racial, ethnic, and socioeconomic groups are well-documented and continue to rise and persist. The reasons are complex, likely involving a combination of patient, provider, and healthcare system factors. Treatment disparities among these different populations have an impact on clinical outcomes, healthcare, and productivity, and are projected to increase significantly with the growing diversity of the United States population. The aim of this short review is to summarize studies of racial, ethnic, and socioeconomic disparities among patients with OA in the United States, with a focus on prevalence, treatment utilization, and clinical and economic outcomes.
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21
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Rivero-Santana A, Torrente-Jiménez RS, Perestelo-Pérez L, Torres-Castaño A, Ramos-García V, Bilbao A, Escobar A, Serrano-Aguilar P, Feijoo-Cid M. Effectiveness of a decision aid for patients with knee osteoarthritis: a randomized controlled trial. Osteoarthritis Cartilage 2021; 29:1265-1274. [PMID: 34174455 DOI: 10.1016/j.joca.2021.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/03/2021] [Accepted: 06/13/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the effectiveness of a Patient Decision Aid (PtDA) for knee osteoarthritis. METHOD Randomized controlled trial, in which 193 patients were allocated to the PtDA or usual care. Outcome measures were the Decisional Conflict Scale (DCS), knowledge of osteoarthritis and arthroplasty, satisfaction with the decision-making process (SDMP) and treatment preference, assessed immediately after the intervention. At 6 months, the same measures were applied in non-operated patients, whereas those who underwent arthroplasty completed the SDMP and the Decisional Regret Scale (DRS). RESULTS The PtDA produced a significant immediate improvement of decisional conflict (MD = -11.65, 95%CI: -14.93, -8.37), objective knowledge (MD = 10.37, 99%IC: 3.15, 17.70) and satisfaction (MD = 6.77, 99%CI: 1.19, 12.34), and a different distribution of preferences (χ2 = 8.74, p = 0.033). Patients with less than secondary education obtained a stronger effect on decisional conflict (p = 0.015 for the interaction) but weaker for knowledge (p = 0.051). At 6 months, there were no significant differences in any variable, including the rate of total knee replacement. Operated patients showed a low level of regret, which was not affected by the intervention. CONCLUSION The PtDA is effective immediately after its application, but it shows no effects in the medium-term. Future research should investigate which subgroups of patients could benefit more from this intervention, as well as the longitudinal evolution of decision-related psychological variables.
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Affiliation(s)
- A Rivero-Santana
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Canary Islands, Spain; Health Services Research on Chronic Patients Network (REDISSEC), Spain.
| | - R S Torrente-Jiménez
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - L Perestelo-Pérez
- Health Services Research on Chronic Patients Network (REDISSEC), Spain; Evaluation Unit of the Canary Islands Health Service (SESCS), Canary Islands, Spain.
| | - A Torres-Castaño
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Canary Islands, Spain; Health Services Research on Chronic Patients Network (REDISSEC), Spain.
| | - V Ramos-García
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Canary Islands, Spain; Health Services Research on Chronic Patients Network (REDISSEC), Spain.
| | - A Bilbao
- Health Services Research on Chronic Patients Network (REDISSEC), Spain; Osakidetza/Basque Health Service, Research Unit, Basurto University Hospital, Bilbao, Bizkaia, Spain.
| | - A Escobar
- Health Services Research on Chronic Patients Network (REDISSEC), Spain; Osakidetza/Basque Health Service, Research Unit, Basurto University Hospital, Bilbao, Bizkaia, Spain
| | - P Serrano-Aguilar
- Health Services Research on Chronic Patients Network (REDISSEC), Spain; Evaluation Unit of the Canary Islands Health Service (SESCS), Canary Islands, Spain.
| | - M Feijoo-Cid
- Department of Nursing, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Grup de Recerca Multidisciplinar en Salut i Societat (GREMSAS), (2017SGR 917), Barcelona, Spain.
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22
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Primeau CA, Birmingham TB, Leitch KM, Willits KR, Litchfield RB, Fowler PJ, Marsh JD, Chesworth BM, Dixon SN, Bryant DM, Giffin JR. Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors. CMAJ 2021; 193:E158-E166. [PMID: 33526542 PMCID: PMC7954572 DOI: 10.1503/cmaj.200934] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND: An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it. METHODS: We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery. RESULTS: Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%–7%) at 5 years and 21% (95% CI 17%–26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12–3.45), pain (adjusted HR 0.85, 95% CI 0.75–0.96)], female sex (adjusted HR 1.67, 95% CI 1.08–2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17–1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12–1.53). INTERPRETATION: We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.
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Affiliation(s)
- Codie A Primeau
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Trevor B Birmingham
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont.
| | - Kristyn M Leitch
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Kevin R Willits
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Peter J Fowler
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Jacquelyn D Marsh
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Bert M Chesworth
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Stephanie N Dixon
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - Dianne M Bryant
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont
| | - J Robert Giffin
- Fowler Kennedy Sport Medicine Clinic (Primeau, Birmingham, Leitch, Willits, Litchfield, Fowler, Bryant, Giffin); School of Physical Therapy, Faculty of Health Sciences (Primeau, Birmingham, Marsh, Chesworth, Bryant); Collaborative Specialization in Musculoskeletal Health Research, Bone and Joint Institute (Primeau); Bone and Joint Institute (Birmingham, Willits, Litchfield, Marsh, Chesworth, Bryant, Giffin); Department of Surgery, Schulich School of Medicine and Dentistry (Willits, Litchfield, Giffin); Department of Epidemiology and Biostatistics (Dixon), Western University; Lawson Health Research Institute (Dixon), London, Ont.
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23
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Simkin J, Valentino J, Cao W, McCarthy C, Schuon J, Davis J, Marrero L, Dasa V, Leonardi C, Yu Q. Quantifying Mediators of Racial Disparities in Knee Osteoarthritis Outcome Scores: A Cross-Sectional Analysis. JB JS Open Access 2021; 6:JBJSOA-D-21-00004. [PMID: 34337283 PMCID: PMC8318640 DOI: 10.2106/jbjs.oa.21.00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Studies on symptomatic osteoarthritis suggest that Black patients report worse pain and symptoms compared with White patients with osteoarthritis. In this study, we aimed to quantify the relationship among variables such as overall health and socioeconomic status that may contribute to disparities in patient-reported outcomes.
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Affiliation(s)
- Jennifer Simkin
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - John Valentino
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Wentao Cao
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Christina McCarthy
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Jonathan Schuon
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Jacob Davis
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Luis Marrero
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Vinod Dasa
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Claudia Leonardi
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
| | - Qingzhao Yu
- Department of Orthopaedic Surgery, School of Medicine, LSUHSC-New Orleans, New Orleans, Louisiana
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24
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Oo WM, Little C, Duong V, Hunter DJ. The Development of Disease-Modifying Therapies for Osteoarthritis (DMOADs): The Evidence to Date. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2921-2945. [PMID: 34262259 PMCID: PMC8273751 DOI: 10.2147/dddt.s295224] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 12/16/2022]
Abstract
Osteoarthritis (OA) is a complex heterogeneous articular disease with multiple joint tissue involvement of varying severity and no regulatory-agency-approved disease-modifying drugs (DMOADs). In this review, we discuss the reasons necessitating the development of DMOADs for OA management, the classifications of clinical phenotypes or molecular/mechanistic endotypes from the viewpoint of targeted drug discovery, and then summarize the efficacy and safety profile of a range of targeted drugs in Phase 2 and 3 clinical trials directed to cartilage-driven, bone-driven, and inflammation-driven endotypes. Finally, we briefly put forward the reasons for failures in OA clinical trials and possible steps to overcome these barriers.
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Affiliation(s)
- Win Min Oo
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar
| | - Christopher Little
- Raymond Purves Bone and Joint Research Laboratories, Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Vicky Duong
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David J Hunter
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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25
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Leu GR, Links AR, Ryan MA, Walsh JM, Tunkel DE, Beach MC, Boss EF. Assessment of Parental Choice Predisposition for Tonsillectomy in Children. JAMA Otolaryngol Head Neck Surg 2021; 147:263-270. [PMID: 33377933 DOI: 10.1001/jamaoto.2020.5031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known. Objective To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication. Design, Setting, and Participants Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist. Main Outcomes and Measures The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents). Results A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34). Conclusions and Relevance In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.
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Affiliation(s)
- Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts
| | - Anne R Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marisa A Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Catherine Beach
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland.,Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Figueroa JF, Burke LG, Horneffer KE, Zheng J, John Orav E, Jha AK. Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities. Health Aff (Millwood) 2021; 39:1065-1071. [PMID: 32479235 DOI: 10.1377/hlthaff.2019.01019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa is an assistant professor of health policy and management in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate physician and assistant professor of medicine in the Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, both in Boston, Massachusetts
| | - Laura G Burke
- Laura G. Burke is an assistant professor of emergency medicine in the Department of Emergency Medicine, Harvard Medical School
| | - Kathryn E Horneffer
- Kathryn E. Horneffer is a research assistant in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston
| | - Jie Zheng
- Jie Zheng is associate director of analytics at the Harvard Global Health Institute, in Cambridge, Massachusetts
| | - E John Orav
- E. John Orav is an associate professor of biostatistics in the Department of Medicine, Brigham and Women's Hospital
| | - Ashish K Jha
- Ashish K. Jha is the director of the Harvard Global Health Institute and is dean of global strategy and the K. T. Li Professor of Global Health, Harvard T. H. Chan School of Public Health
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27
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Bove AM, Dong ER, Hausmann LRM, Piva SR, Brach JS, Lewis A, Fitzgerald GK. Exploring Race Differences in Satisfaction with Rehabilitation Following Total Knee Arthroplasty: a Qualitative Study. J Gerontol A Biol Sci Med Sci 2021; 77:e48-e55. [PMID: 33978153 DOI: 10.1093/gerona/glab132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this qualitative focus group study was to explore race differences in the rehabilitation experience and satisfaction with rehabilitation following total knee arthroplasty (TKA). METHODS We conducted a series of qualitative focus group discussions with groups of Non-Hispanic White and Non-Hispanic Black older adults who recently underwent TKA. We used grounded theory approach, which asks the researcher to develop theory from the data that are collected. Participants discussed barriers and facilitators to accessing rehabilitation after surgery, opinions regarding their physical therapists, the amount of post-operative physical therapy received, and overall satisfaction with the post-operative rehabilitation process. RESULTS Thirty-six individuals participated in focus groups. Three major themes emerged: (1) Participants reported overall positive views of their post-TKA rehabilitation experience. They particularly enjoyed one-on-one care, the ability to participate in "prehabilitation", and often mentioned specific interventions they felt were most helpful in their recovery. (2) Despite this, substantial barriers to accessing physical therapy exist. These include suboptimal pain management, copayments and other out-of-pocket costs, and transportation to visits. (3) There were minor differences in the rehabilitation experiences between Black and White participants. Black participants reported longer paths toward surgery and occasional difficulty interacting with rehabilitation providers. CONCLUSIONS Individuals undergoing TKA can largely expect positive rehabilitation experiences post-operatively. However, some barriers to post-operative physical therapy exist and may differ between Black and White patients. Physical therapists should increase their awareness of these barriers and work to minimize them whenever possible.
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Affiliation(s)
- Allyn M Bove
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences; Pittsburgh, PA, USA
| | - Erin R Dong
- Penn Presbyterian Medical Center; Philadelphia, PA, USA
| | - Leslie R M Hausmann
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System; Pittsburgh, PA, USA
| | - Sara R Piva
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences; Pittsburgh, PA, USA
| | - Jennifer S Brach
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences; Pittsburgh, PA, USA
| | - Allen Lewis
- School of Health Professions, SUNY Downstate Health Sciences University; Brooklyn, NY, USA
| | - G Kelley Fitzgerald
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences; Pittsburgh, PA, USA
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28
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Vina ER, Hannon MJ, Quinones C, Hausmann LRM, Ibrahim SA, Dagnino J, Kwoh CK. The Role of Knowledge and Attitudes About Nonsteroidal Anti-inflammatory Drugs in Determining Treatment Use. ACR Open Rheumatol 2021; 3:154-163. [PMID: 33570233 PMCID: PMC7966879 DOI: 10.1002/acr2.11235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti-inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA). METHODS Surveys of 334 adults with knee and/or hip OA were analyzed in this cross-sectional study. Familiarity with and perceptions of benefits/risks of NSAID use were measured to assess associations with the use of prescription and nonprescription oral NSAIDs. Multinomial logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS In this sample, 35.9% and 35.6% reported use of oral prescription and nonprescription-only NSAIDs, respectively. Hispanic participants, compared with non-Hispanic White participants, had lower perceived benefit (P = 0.005) and risk (P = 0.001) of prescription NSAIDs. The following were associated with prescription NSAID use instead of no NSAID use: having family/friends who used prescription (relative risk ratio [RRR] 3.91; 95% confidence interval [CI] 2.05-7.47) and over-the-counter (OTC) (RRR 3.10; 95% CI 1.65-5.83) NSAIDs for OA, understanding the consequences of using both prescription (RRR 3.50; 95% CI 1.79-6.86) and OTC (RRR 2.80; 95% CI 1.39-5.65) NSAIDs, higher perceived benefit of both prescription (RRR 2.51; 95% CI 1.71-3.66) and OTC (RRR 1.44; 95% CI 1.01-2.06) NSAIDs, and lower perceived risk of both types of NSAIDs (prescription: RRR 0.63 [95% CI 0.46-0.87]; OTC: RRR 0.53 [95% CI 0.37-0.75]). Similar results were found when we assessed the relationship between these variables and OTC NSAID use versus no oral NSAID use. CONCLUSION Adults with knee and/or hip OA were more likely to use NSAIDs if they were more familiar with, had an increased perceived benefit of, and had a decreased perceived risk of these drugs. Patients' perceptions and beliefs about NSAIDs should be evaluated when considering them for treatment.
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Affiliation(s)
| | | | | | - L. R. M. Hausmann
- US Department of Veterans Affairs Pittsburgh Healthcare System and University of PittsburghPittsburghPennsylvania
| | - S. A. Ibrahim
- Weill Cornell MedicineCornell UniversityNew YorkNew York
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29
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Abstract
This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.
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Affiliation(s)
- Angel M Reyes
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, BWH Orthopaedics, OrACORe Group, 75 Francis Street, BTM Suite 5016, Boston, MA 02115, USA.
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, BWH Orthopaedics, OrACORe Group, 75 Francis Street, BTM Suite 5016, Boston, MA 02115, USA; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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30
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Hettrich CM, Zacharias A, Ortiz SF, Westgate P, Wolf BR, Jacobs C. Are there racial differences between patients undergoing surgery for shoulder instability? Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Group. J Shoulder Elbow Surg 2021; 30:229-236. [PMID: 33166646 DOI: 10.1016/j.jse.2020.09.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. METHODS Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient's home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. RESULTS Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. CONCLUSION We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.
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Affiliation(s)
- Carolyn M Hettrich
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Anthony Zacharias
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA.
| | - Shannon F Ortiz
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Philip Westgate
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Brian R Wolf
- Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Cale Jacobs
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA
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31
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Katz JN. Persistent Racial Disparities in Joint Replacement Use: Commentary on an article by Caroline P. Thirukumaran, MBBS, MHA, PhD, et al.: "Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017". J Bone Joint Surg Am 2020; 102:e137. [PMID: 33347011 DOI: 10.2106/jbjs.20.01764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jeffrey N Katz
- Department of Orthopedic Surgery and Division of Rheumatology, Immunity, and Inflammation, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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32
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Hutyra CA, Gonzalez JM, Yang JC, Johnson FR, Reed SD, Amendola A, Bolognesi MP, Berend KR, Berend ME, MacDonald SJ, Mather RC. Patient Preferences for Surgical Treatment of Knee Osteoarthritis: A Discrete-Choice Experiment Evaluating Total and Unicompartmental Knee Arthroplasty. J Bone Joint Surg Am 2020; 102:2022-2031. [PMID: 33027086 DOI: 10.2106/jbjs.20.00132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common treatment for end-stage knee osteoarthritis but is associated with increased complication rates compared with unicompartmental knee arthroplasty (UKA). UKA offers better functional outcomes but is associated with a higher risk of revision. The purpose of this study was to apply good-practice, stated-preference methods to quantify patient preferences for benefit-risk tradeoffs associated with arthroplasty treatments for end-stage knee osteoarthritis. METHODS A discrete-choice experiment was developed with the following attributes: chance of complications, functional ability, awareness of the knee implant, and chance of needing another operation within 10 years. Patients included those aged 40 to 80 years with knee osteoarthritis. A pivot design filtered respondents into 1 of 2 surveys on the basis of self-reported functional ability (good compared with fair or poor) as measured by the Oxford Knee Score. Treatment-preference data were collected, and relative attribute-importance weights were estimated. RESULTS Two hundred and fifty-eight completed survey instruments from 92 males and 164 females were analyzed, with 72 respondents in the good-function cohort and 186 in the fair/poor-function cohort. Patients placed the greatest value or relative importance on serious complications and rates of revision in both cohorts. Preference weights did not vary between cohorts for any attribute. In the good-function cohort, 42% of respondents chose TKA and 58% chose UKA. In the fair/poor-function cohort, 54% chose TKA and 46% chose UKA. CONCLUSIONS Patient preferences for various treatment attributes varied among patients in a knee osteoarthritis population. Complication and revision rates were the most important factors to patients, suggesting that physicians should focus on these areas when discussing treatments. The proportion of patients who chose UKA suggests that the current trend of increased UKA utilization is aligned with patient preferences. CLINICAL RELEVANCE Systematic elicitation of patient preferences for knee arthroplasty procedures, which lays out evidence-based risks and benefits of different treatments, indicates a larger subset of the knee osteoarthritis population may prefer UKA than would be suggested by the current rates of utilization of the procedure. Arthroplasty treatment should align with patient preferences and eligibility criteria to better deliver patient-centered care.
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Affiliation(s)
- Carolyn A Hutyra
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Jui-Chen Yang
- Pacific Economic Research, LLC, Bellevue, Washington
| | - F Reed Johnson
- Duke Clinical Research Institute, Durham, North Carolina
| | - Shelby D Reed
- Duke Clinical Research Institute, Durham, North Carolina
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, Ohio.,White Fence Surgical Suites, New Albany, Ohio.,Mount Carmel New Albany Surgical Hospital, New Albany, Ohio
| | | | - Steven J MacDonald
- Division of Orthopaedic Surgery, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Williams JN, Ford CL, Morse M, Feldman CH. Racial Disparities in Rheumatology Through the Lens of Critical Race Theory. Rheum Dis Clin North Am 2020; 46:605-612. [PMID: 32981638 DOI: 10.1016/j.rdc.2020.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
According to critical race theory (CRT), racism is ubiquitous in society. In the field of medicine, systems of racism are subtly interwoven with patient care, medical education, and medical research. Public health critical race praxis (PHCRP) is a tool that allows researchers to apply CRT to research. This article discusses the application of CRT and PHCRP to 3 race-related misconceptions in rheumatology: (1) giant cell arteritis is rare in non-White populations; (2) Black patients are less likely to undergo knee replacement because of patient preference; and (3) HLA-B*5801 screening should only be performed for patients of Asian descent.
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Affiliation(s)
- Jessica N Williams
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Chandra L Ford
- Department of Community Health Sciences, Jonathan & Karin Fielding School of Public Health, University of California at Los Angeles, Box 951772, 650 Charles East Young Drive, South, Los Angeles, CA 90095-1772, USA
| | - Michelle Morse
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Candace H Feldman
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Office #6016P, Boston, MA 02115, USA
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Nowell WB, Venkatachalam S, Stake C, Harden E, Fraenkel L, Peters E, Concannon TW. Identifying patient decisions and related information needs during decision making related to total knee arthroplasty. J Comp Eff Res 2020; 9:1153-1166. [PMID: 33124898 DOI: 10.2217/cer-2020-0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aim: Research regarding decisions patients make about total knee arthroplasty, apart from having the procedure or not, are limited. Understanding patient decision making and related information needs is essential for shared decision making. Methods: Focus groups with an online community-based sample identified decisions about total knee arthroplasty beyond the decision to have the surgery itself. An online survey was used to determine relative importance of five major decisions and evaluate related information available. Results: Patients did not feel they have enough information to make important decisions of surgeon, device type, surgical approach, facility, or timing, for their total knee arthroplasty. Conclusion: Although further research is needed to generalize these findings, physicians should consider these questions during shared decision making with patients considering total knee arthroplasty.
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Affiliation(s)
| | | | - Christine Stake
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Erik Harden
- Columbia University Irving Medical, New York, NY, USA
| | - Liana Fraenkel
- Yale University School of Medicine, New Haven, CT; Berkshire Health Systems, Pittsfield, MA, USA
| | - Ellen Peters
- University of Oregon School of Journalism & Communication, Eugene, OR, USA
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Venugopal V, Gronbeck C, Harvey L, Patel AP, Harrington MA, Halawi MJ. Time Trends in Perioperative Characteristics and Health Outcomes in Hispanic Patients Undergoing Primary Total Knee Arthroplasty. J Racial Ethn Health Disparities 2020; 8:1475-1481. [DOI: 10.1007/s40615-020-00910-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/23/2022]
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Vina ER, Quinones C. Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care. Rheum Dis Clin North Am 2020; 47:83-96. [PMID: 34042056 DOI: 10.1016/j.rdc.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.
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Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA.
| | - Cristian Quinones
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA
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Cusano A, Venugopal V, Gronbeck C, Harrington MA, Halawi MJ. Where Do We Stand Today on Racial and Ethnic Health Inequities? Analysis of Primary Total Knee Arthroplasty from a 2011-2017 National Database. J Racial Ethn Health Disparities 2020; 8:1178-1184. [PMID: 32940894 DOI: 10.1007/s40615-020-00875-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of this study was to present contemporary national data on the state of racial and ethnic disparities pertaining to primary total knee arthroplasty (TKA) in the USA. METHODS The 2011-2017 National Surgical Quality Improvement Program was used to capture all patients who underwent primary TKA. The study outcomes were differences in demographic, comorbidity burden, perioperative factors, procedure utilization, hospital length of stay (LOS), and 30-day outcomes. The five major minority groups as defined by the National Institutes of Health were compared to non-Hispanic Whites. RESULTS In total, 262,954 patient records were analyzed, with racial identification available on 230,712 patients (87.7%). White patients accounted for 72.5% of all TKA procedures. There were higher rates of diabetes, hypertension, anemia, and prolonged surgery times among racial and ethnic minorities (p < 0.001). Baseline disparities were especially pronounced among non-Hispanic Blacks/African Americans who were also like to have higher rates of tobacco smoking and CHF (p < 0.001). After controlling for baseline differences, significant disparities in outcomes persisted, especially among Blacks/African Americans and Hispanics/Latinos who had higher odds for experiencing complications and readmissions (p < 0.001). All racial and ethnic groups, except Asians, had longer LOS (p < 0.001). Asian patients had significantly lower rates of readmissions, reoperations, and overall complications (p < 0.001). CONCLUSION Racial and ethnic disparities remain a public health challenge for patients undergoing TKA. While initiatives aimed at improving preoperative disease-burden and comorbidity profiles represent an important step, they alone are insufficient to fully account for or eliminate the disparities in TKA outcomes.
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Affiliation(s)
- Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Vivek Venugopal
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA
| | | | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA.
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Orhurhu V, Gao C, Agudile E, Monegro W, Urits I, Orhurhu MS, Olatoye D, Viswanath O, Hirji S, Jones M, Ngo A, Aiudi C, Simopoulos T, Gill J. Socioeconomic Disparities in the Utilization of Spinal Cord Stimulation Therapy in Patients with Chronic Pain. Pain Pract 2020; 21:75-82. [PMID: 32654360 DOI: 10.1111/papr.12936] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) therapies are used in the management of patients with complex regional pain syndrome I (CRPS I) and failed back surgery syndrome (FBSS). The purpose of this study was to investigate the racial and health insurance inequalities with SCS therapy in patients with chronic pain who had CRPS I and FBSS. METHODS Patients with chronic pain who had a discharge diagnosis of FBSS and CRPS I were identified using the National Inpatient Sample database. Our primary outcome was defined as the history of SCS utilization by race/ethnicity, income quartile, and insurance status. Multivariable logistic regression was used to determine the variables associated with utilization of SCS therapy. RESULTS Between 2011 and 2015, 40,858 patients who were hospitalized with a primary diagnosis of FBSS and/or CRPS I were identified. Of these patients, 1,082 (2.7%) had a history of SCS therapy. Multivariable regression analysis revealed that compared to White patients, Black and Hispanic patients had higher odds of having SCS therapy (Black patients: odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.12 to 1.77; P = 0.003; Hispanic patients: OR = 1.41; 95% CI, 1.10 to 1.81; P = 0.007). Patients with private insurance had significantly higher odds of having SCS therapy compared with those with Medicare (OR = 1.24; 95% CI, 1.08 to 1.43; P = 0.003). Compared to patients with Medicare, Medicaid patients had lower odds of having SCS therapy (OR = 0.50; 95% CI, 0.36 to 0.70; P < 0.001). CONCLUSIONS Our study suggests that socioeconomic disparities may exist in the utilization of SCS among hospitalized patients with CRPS I and FBSS the United States. However, confirming these data from other administrative databases, in the outpatient setting, may shed more insight.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Catherine Gao
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A
| | - Emeka Agudile
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, U.S.A
| | - Wendy Monegro
- Department of Nursing, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mariam Salisu Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Dare Olatoye
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Omar Viswanath
- Department of Anesthesiology, Valley Anesthesiology and Pain Consultants, Phoenix, Arizona, U.S.A.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, U.S.A.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, Nebraska, U.S.A
| | - Sameer Hirji
- Departments of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mark Jones
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Anh Ngo
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Pain Medicine, Pain Specialty Group, Newington, New Hampshire, U.S.A
| | - Christopher Aiudi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Thomas Simopoulos
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jatinder Gill
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
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Leung K, Zhang B, Tan J, Shen Y, Geras KJ, Babb JS, Cho K, Chang G, Deniz CM. Prediction of Total Knee Replacement and Diagnosis of Osteoarthritis by Using Deep Learning on Knee Radiographs: Data from the Osteoarthritis Initiative. Radiology 2020; 296:584-593. [PMID: 32573386 DOI: 10.1148/radiol.2020192091] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The methods for assessing knee osteoarthritis (OA) do not provide enough comprehensive information to make robust and accurate outcome predictions. Purpose To develop a deep learning (DL) prediction model for risk of OA progression by using knee radiographs in patients who underwent total knee replacement (TKR) and matched control patients who did not undergo TKR. Materials and Methods In this retrospective analysis that used data from the OA Initiative, a DL model on knee radiographs was developed to predict both the likelihood of a patient undergoing TKR within 9 years and Kellgren-Lawrence (KL) grade. Study participants included a case-control matched subcohort between 45 and 79 years. Patients were matched to control patients according to age, sex, ethnicity, and body mass index. The proposed model used a transfer learning approach based on the ResNet34 architecture with sevenfold nested cross-validation. Receiver operating characteristic curve analysis and conditional logistic regression assessed model performance for predicting probability and risk of TKR compared with clinical observations and two binary outcome prediction models on the basis of radiographic readings: KL grade and OA Research Society International (OARSI) grade. Results Evaluated were 728 participants including 324 patients (mean age, 64 years ± 8 [standard deviation]; 222 women) and 324 control patients (mean age, 64 years ± 8; 222 women). The prediction model based on DL achieved an area under the receiver operating characteristic curve (AUC) of 0.87 (95% confidence interval [CI]: 0.85, 0.90), outperforming a baseline prediction model by using KL grade with an AUC of 0.74 (95% CI: 0.71, 0.77; P < .001). The risk for TKR increased with probability that a person will undergo TKR from the DL model (odds ratio [OR], 7.7; 95% CI: 2.3, 25; P < .001), KL grade (OR, 1.92; 95% CI: 1.17, 3.13; P = .009), and OARSI grade (OR, 1.20; 95% CI: 0.41, 3.50; P = .73). Conclusion The proposed deep learning model better predicted risk of total knee replacement in osteoarthritis than did binary outcome models by using standard grading systems. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Richardson in this issue.
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Affiliation(s)
- Kevin Leung
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Bofei Zhang
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Jimin Tan
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Yiqiu Shen
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Krzysztof J Geras
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - James S Babb
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Kyunghyun Cho
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Gregory Chang
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
| | - Cem M Deniz
- From the Courant Institute of Mathematical Sciences (K.L., K.C.) and Center for Data Science (B.Z., J.T., Y.S., K.J.G., K.C.), New York University, New York, NY; The Bernard and Irene Schwartz Center for Biomedical Imaging (K.J.G., J.S.B., C.M.D.) and Department of Radiology (K.J.G., J.S.B., G.C., C.M.D.), New York University Langone Health, 660 1st Ave, New York, NY 10016
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Racial and Ethnic Health Services Disparities in Pediatric Anesthesia Practice: A Scoping Review. J Racial Ethn Health Disparities 2020; 8:384-393. [PMID: 32533531 DOI: 10.1007/s40615-020-00792-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
Racial and ethnic disparities in pediatric anesthesia health services could result in minority children being at increased risk of poor outcomes, such as pain, anxiety, or over-exposure to medications. Yet, a comprehensive understanding of the literature on such disparities does not exist to date. The objective of this study is to describe health services disparities in pediatric anesthetic care in the pre-, intra-, or post-operative period by synthesizing current literature. We searched the National Library of Medicine's PubMed/Medline, Embase, and Web of Science for articles published between January 1, 2007, and May 9, 2020, to identify literature on racial and ethnic health services disparities in pediatric anesthesia. We used the Institute of Medicine's definition of disparities. Health services were related to pre-, intra-, or post-operative anesthetic care of pediatric patients (< 18 years old). Out of 2110 studies, 10 studies met the criteria for inclusion. Nine out of the ten articles were single-institutional observational studies, based at tertiary hospitals. Sample sizes ranged from 74 to 37,618 discrete participants, for a total of 69,350 subjects across all studies. Results of these studies present low-quality evidence and heterogeneous conclusions regarding pediatric anesthesia health services disparities. This review demonstrates the paucity and diversity of research on racial and ethnic disparities in pediatric anesthesia health services and suggests how future work might utilize improved data and rigorous study designs.
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Bendich I, Halvorson RT, Ward D, Nevitt M. Predictors of a change in patient willingness to have Total knee arthroplasty: Insights from the osteoarthritis initiative. Knee 2020; 27:667-675. [PMID: 32563421 DOI: 10.1016/j.knee.2020.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND While many factors have been shown to influence patient willingness to have total joint arthroplasty, factors associated with changes in patient willingness to have arthroplasty have not been studied. The objective of this research is to identify predictors of change in patient willingness to have total knee arthroplasty (TKA). METHODS Patient willingness to have TKA as well as questionnaire, clinical, and radiographic data, were obtained from the Osteoarthritis Initiative (OAI) for individuals with, or at high risk for developing knee OA. Mixed effects ordinal logistic regressions were employed to assess the relationships between 40 predictors and change in willingness to have surgery. Predictors significant in univariate models were included in a multivariable analysis. RESULTS Three thousand three hundred and ninety-four OAI patients were included in our analysis. Between baseline and follow-up, 462 (13.6%) became more willing and 533 (15.7%) became less willing to have TKA. After controlling for demographic factors in multivariable analysis, patients with higher income and expected difficulty with postoperative walking were more likely to increase their willingness to have TKA. General health, race, and knee injections within the past six months approached significance with regard to increasing willingness to have TKA over time. CONCLUSION Income and expectations of difficulty walking postoperatively were significantly associated with changes in patient willingness to have TKA independent of age, sex, health coverage, employment, marriage status, and knee pain. Understanding factors influencing patient willingness to have surgery may be instrumental in counseling and addressing the mismatch of OA disease burden to surgical utilization.
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Affiliation(s)
- Ilya Bendich
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave. MU W320, San Francisco, CA 94143, United States of America
| | - Ryan T Halvorson
- School of Medicine, University of California, San Francisco. 500 Parnassus Ave. San Francisco, CA 94143, United States of America.
| | - Derek Ward
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Ave. MU W320, San Francisco, CA 94143, United States of America
| | - Michael Nevitt
- Department of Epidemiology and Biostatistics, University of California, 550 16th St, San Francisco, CA 94158, United States of America
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Building a predictive model of U.S. patient willingness to undergo robotic surgery. J Robot Surg 2020; 15:203-214. [PMID: 32452012 DOI: 10.1007/s11701-020-01092-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/12/2020] [Indexed: 01/10/2023]
Abstract
Prior research regarding robotic surgery (RS) has largely focused on the engineering or medical aspects of these tools. A few studies have examined consumer opinions toward, or willingness to use, robotic surgeons; however, no study to date has examined what type of person would be willing to undergo RS. Across two studies, the current research fills this gap by building both a descriptive and predictive regression model used to predict what type of user would be willing to undergo RS. To build the descriptive model, 1324 potential patients were asked a series of questions about demographics, attitudes, opinions, and personalities. Results indicate that perceived value, familiarity, wariness of new technologies, fear of surgery, openness, anger, fear, and happiness are all significant predictors of willingness to undergo RS. A regression equation was developed and then used to predict scores in a second study with 1335 potential patients. The scores from both studies were compared for model fit. Several methods were used to validate the regression model, including correlational analyses, a t test, and calculation of the cross-validity coefficient. All three stringent tests showed strong model fit, explaining 62% of the variance in the model. These findings have both practical and theoretical values to the field and can be used to identify early adopters of this advanced medical technology.
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Hurley VB, Rodriguez HP, Kearing S, Wang Y, Leung MD, Shortell SM. The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery. Health Aff (Millwood) 2020; 39:100-107. [PMID: 31905066 PMCID: PMC7082857 DOI: 10.1377/hlthaff.2019.00100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.
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Affiliation(s)
- Vanessa B Hurley
- Vanessa B. Hurley ( vh151@georgetown. edu ) is an assistant professor of Health Systems Administration at the Georgetown University School of Nursing and Health Studies, in Washington, D.C
| | - Hector P Rodriguez
- Hector P. Rodriguez is the Henry J. Kaiser Professor of Health Policy and Management and codirector of the Center for Healthcare Organizational and Innovation Research, both at the University of California (UC) Berkeley School of Public Health
| | - Stephen Kearing
- Stephen Kearing is a Reporting and Analytics programmer at the High Value Healthcare Collaborative, in Hanover, New Hampshire
| | - Yue Wang
- Yue Wang is a data analyst in the Center for Healthcare Organizational and Innovation Research, UC Berkeley School of Public Health
| | - Ming D Leung
- Ming D. Leung is an associate professor of organization and management at the UC Irvine Paul Merage School of Business
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor Emeritus of Health Policy and Management, a professor of organization behavior at the School of Public Health and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at UC Berkeley
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Cavanaugh AM, Rauh MJ, Thompson CA, Alcaraz J, Mihalko WM, Bird CE, Eaton CB, Rosal MC, Li W, Shadyab AH, Gilmer T, LaCroix AZ. Racial and ethnic disparities in utilization of total knee arthroplasty among older women. Osteoarthritis Cartilage 2019; 27:1746-1754. [PMID: 31404657 PMCID: PMC6875623 DOI: 10.1016/j.joca.2019.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/14/2019] [Accepted: 07/31/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate racial and ethnic disparities in utilization of total knee arthroplasty (TKA) in relation to demographic, health, and socioeconomic status variables. DESIGN Prospective study of 102,767 Women's Health Initiative postmenopausal women initially aged 50-79, examining utilization rates of primary TKA between non-Hispanic Black/African American, non-Hispanic White, and Hispanic/Latina women (hereafter referred to as Black, White, and Hispanic). A total of 8,942 Black, 3,405 Hispanic, and 90,420 White women with linked Medicare claims data were followed until time of TKA, death, or transition from fee-for-service coverage. Absolute disparities were determined using utilization rates by racial/ethnic group and relative disparities quantified using multivariable hazards models in adjusting for age, arthritis, joint pain, mobility disability, body mass index, number of comorbidities, income, education, neighborhood socioeconomic status (SES), and geographic region. RESULTS TKA utilization was higher among White women (10.7/1,000 person-years) compared to Black (8.5/1,000 person-years) and Hispanic women (7.6/1,000 person-years). Among women with health indicators for TKA including diagnosis of arthritis, moderate to severe joint pain, and mobility disability, Black and Hispanic women were significantly less likely to undergo TKA after adjusting for age [Black: HR (95% confidence interval) = 0.70 (0.63-0.79); Hispanic: HR = 0.58 (0.44-0.77)]. Adjustment for SES modestly attenuated the measured disparity, but significant differences remained [Black: HR = 0.75 (0.67-0.89); Hispanic: HR = 0.65 (0.47-0.89)]. CONCLUSIONS Compared to White women, Black and Hispanic women were significantly less likely to undergo TKA after considering need and appropriateness for TKA and SES. Further investigation into personal-level and provider-level factors that may explain these disparities is warranted.
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Affiliation(s)
- A M Cavanaugh
- San Diego State University/University of California San Diego, Joint Doctoral Program in Public Health, USA.
| | - M J Rauh
- Doctor of Physical Therapy Program, San Diego State University, San Diego, CA, USA; Graduate School of Public Health, San Diego State University, San Diego, CA, USA.
| | - C A Thompson
- Graduate School of Public Health, San Diego State University, San Diego, CA, USA.
| | - J Alcaraz
- Graduate School of Public Health, San Diego State University, San Diego, CA, USA.
| | - W M Mihalko
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee, Memphis, TN, USA.
| | - C E Bird
- Health Care Division, RAND, Santa Monica, CA, USA.
| | - C B Eaton
- Department of Family Medicine at Warren Alpert Medical School and Department of Epidemiology at School of Public Health at Brown University, Providence, RI, USA.
| | - M C Rosal
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, USA.
| | - W Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - A H Shadyab
- Department of Family Medicine and Public Health, University of California, San Diego, CA, USA.
| | - T Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, CA, USA.
| | - A Z LaCroix
- Department of Family Medicine and Public Health, University of California, San Diego, CA, USA.
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Zelle BA, Morton-Gonzaba NA, Adcock CF, Lacci JV, Dang KH, Seifi A. Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures. J Orthop Surg Res 2019; 14:359. [PMID: 31718674 PMCID: PMC6852936 DOI: 10.1186/s13018-019-1402-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Socio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA. Methods The National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment. Results A total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p < 0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p < 0.05). Conclusions Besides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA.
| | - Nicolas A Morton-Gonzaba
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Christopher F Adcock
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - John V Lacci
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Khang H Dang
- Department of Orthopaedic Surgery, UT Health San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX, 78229, USA
| | - Ali Seifi
- Department of Neurosurgery-Neuro Critical Care, UT Health San Antonio, San Antonio, TX, USA
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Hanson AL, Crosby RD, Basson MD. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg 2019; 153:471-478. [PMID: 29322168 DOI: 10.1001/jamasurg.2017.5310] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective. Objectives To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing. Design, Setting, and Participants This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017. Main Outcomes and Measures Treatment preferences. Results Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as "gender fluid" within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P < .001), identified as other than non-Hispanic white (24 [14.9%]; P < .001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P = .02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment-rather than reductions in the duration of hospitalization or antibiotic treatment-were more likely to increase the desirability of choosing antibiotics. Conclusions and Relevance Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.
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Affiliation(s)
- Alexis L Hanson
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks
| | - Ross D Crosby
- Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Grand Forks.,Neuropsychiatric Research Institute, Fargo, North Dakota
| | - Marc D Basson
- Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks
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Kraus VB, Simon LS, Katz JN, Neogi T, Hunter D, Guermazi A, Karsdal MA. Proposed study designs for approval based on a surrogate endpoint and a post-marketing confirmatory study under FDA's accelerated approval regulations for disease modifying osteoarthritis drugs. Osteoarthritis Cartilage 2019; 27:571-579. [PMID: 30465809 DOI: 10.1016/j.joca.2018.11.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
In 1992, the Food and Drug Administration (FDA) instituted the accelerated approval regulations that allow drugs or biologics for serious conditions that fill an unmet medical need to be approved on the basis of a surrogate endpoint or an intermediate clinical endpoint. The current definition of a serious condition includes chronic disabling conditions, such as osteoarthritis (OA), and thereby provides expanded opportunities for the use of biomarkers for regulatory approval of drugs for OA. The use of surrogates or intermediate clinical endpoints for initial regulatory approval of a drug or biologic requires confirmation in a post-marketing study of a drug effect on a clinically relevant outcome, such as on how a patient feels, functions or survives. Current FDA guidance requires that the post-marketing approval (PMA) study be ongoing during the time of initial drug approval. This white paper arose out of the need to brainstorm trial designs that might be suitable for PMA of drugs initially approved, on the basis of a surrogate or intermediate clinical endpoint, for treatment of OA to alter disease progression, abnormal function or pathological changes in the morphology of the joint. In this white paper we define the concept and regulations regarding accelerated approval and propose two major study design scenarios for PMA trials in OA. The long-term goal is to discuss and refine these designs in consultation with regulatory agencies in order to facilitate development of drugs to fill the large unmet need in OA.
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Affiliation(s)
- V B Kraus
- Duke Molecular Physiology Institute, Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | | | - J N Katz
- Brigham and Women's Hospital, Boston, MA, USA
| | - T Neogi
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - D Hunter
- University of Sydney, Sydney, Australia
| | - A Guermazi
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - M A Karsdal
- Nordic Bioscience A/S, Herlev Hovedgade 207, DK-2730 Herlev, Denmark
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48
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Fox J, Lekoubou A, Bishu KG, Ovbiagele B. Recent patterns of vagal nerve stimulator use in the United States: Is there a racial disparity? Epilepsia 2019; 60:756-763. [PMID: 30875432 DOI: 10.1111/epi.14695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Patients with refractory epilepsy are at a high risk of complications but may not receive the same level of care across racial groups. We aimed to ascertain racial inequalities and trends in the use of a vagal nerve stimulator (VNS) among adult patients with refractory epilepsy. METHODS A total of 24 159 adults (18 years and older) with refractory epilepsy from the National Inpatient Sample between the years 2006 and 2014 were included in this analysis. We used a multivariate logistic regression analysis to evaluate independent predictors of VNS use among patients with refractory epilepsy. Covariates included gender, age, insurance type, and household income. In addition, we evaluated for trends in VNS use over the 9-year period of data collection. RESULTS A total of 1.56% of patients with refractory epilepsy had used a VNS between 2006 and 2014. Overall, there was a trend of decreased use of a VNS between 2006-2008 (2.1%) and 2012-2014 (0.9%). In the adjusted multivariate logistic regression analysis, blacks (odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.77) were significantly less likely to have used a VNS relative to non-Hispanic whites. Additional factors independently associated with a decreased likelihood of VNS use were age > 65 years (OR = 0.51, 95% CI = 0.28-0.95) and years 2012-2014 (OR = 0.44, 95% CI = 0.28-0.67). SIGNIFICANCE There was a trend toward a decrease in the use of a VNS among adult patients with refractory epilepsy. Our results also suggest that black patients with refractory epilepsy were less likely to receive a VNS independently of other variables. Increased work toward effectively reducing racial disparities in access to quality epilepsy care is crucial.
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Affiliation(s)
- Jonah Fox
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - Alain Lekoubou
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.,Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, South Carolina
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, California
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Yin C, Sing DC, Curry EJ, Abdul-Rassoul H, Galvin JW, Eichinger JK, Li X. The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis. Orthopedics 2019; 42:95-102. [PMID: 30810757 DOI: 10.3928/01477447-20190221-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/04/2019] [Indexed: 02/03/2023]
Abstract
There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].
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50
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Vaughn IA, Terry EL, Bartley EJ, Schaefer N, Fillingim RB. Racial-Ethnic Differences in Osteoarthritis Pain and Disability: A Meta-Analysis. THE JOURNAL OF PAIN 2018; 20:629-644. [PMID: 30543951 DOI: 10.1016/j.jpain.2018.11.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 01/12/2023]
Abstract
Osteoarthritis (OA), a leading cause of disability and pain, affects 32.5 million Americans, producing tremendous economic burden. Although some findings suggest that racial/ethnic minorities experience increased OA pain severity, other studies have shown conflicting results. This meta-analysis examined differences in clinical pain severity between African Americans (AAs) and non-Hispanic whites with OA. Articles were initially identified between October 1 and 5, 2016, and updated May 30, 2018, using PubMed, Web of Science, PsycINFO, and the Cochrane Library Database. Eligibility included English-language peer-reviewed articles comparing clinical pain severity in adult black/AA and non-Hispanic white/Caucasian patients with OA. Nonduplicate article abstracts (N = 1,194) were screened by 4 reviewers, 224 articles underwent full-text review, and 61 articles reported effect sizes of pain severity stratified by race. Forest plots of the standard mean difference showed higher pain severity in AAs for studies using the Western Ontario and McMasters Universities Osteoarthritis Index (0.57; 95% confidence interval [CI], 0.54-0.61) and non-Western Ontario and McMasters Universities Osteoarthritis Index studies (0.35, 95% CI, 0.23-0.47). AAs also showed higher self-reported disability (0.38, 95% CI, 0.22-0.54) and poorer performance testing (-0.58, 95% CI, -0.72 to -0.44). Clinical pain severity and disability in OA is higher among AAs and future studies should explore the reasons for these differences to improve pain management. PERSPECTIVE: This meta-analysis shows that differences exist in clinical pain severity, functional limitations, and poor performance between AAs and non-Hispanic whites with OA. This research may lead to a better understanding of racial/ethnic differences in OA-related pain.
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Affiliation(s)
- Ivana A Vaughn
- Department of Health Services Research, Management & Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida.
| | - Ellen L Terry
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Emily J Bartley
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Nancy Schaefer
- Health Science Center Libraries, University of Florida, Gainesville, Florida
| | - Roger B Fillingim
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
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