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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Insurance. J Arthroplasty 2024; 39:1637-1639. [PMID: 38360281 DOI: 10.1016/j.arth.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Edwards MA, Falstin M, Uddandam A, Brennan E, Spaulding A. Caprini guideline indicated venous thromboembolism (VTE) prophylaxis among inpatient surgical patients: are there racial/ethnic differences in practice patterns and outcomes? Am J Surg 2024:115785. [PMID: 38849278 DOI: 10.1016/j.amjsurg.2024.115785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/04/2024] [Accepted: 05/27/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND While racial disparity in surgical mortality due to venous thromboembolism (VTE) has improved, a gap persists. Our study aim was to determine differences in VTE prevention practices and their impact on outcomes among racial surgical cohorts. METHODS Elective surgeries performed between 1.1.2016 and 5.31.2021 were included. Racial/ethnic cohorts were propensity-matched 1:1 to non-Hispanic White (NHW) patients, and outcomes were compared using unadjusted logistic regression. Match cohort balance was assessed using absolute standardized mean differences and linear model analysis of variance (ANOVA). Pearson's Chi-square tests evaluated bi-variate associations. Conditional logistic regression to compare outcomes between matched groups. Odds ratios, 95 % confidence intervals, and p-values are reported. Analyses were performed using R version 4.1.2 and the R package Matchit. RESULTS Non-Hispanic other race (NHOR) (vs. NHW) patients were less likely to receive inpatient prophylaxis (OR 0.86, CI:0.76-0.98). Appropriate prophylaxis resulted in similar VTE for NHB (p = 0.71) and Hispanic (p = 0.06), compared to NHW patients. Inpatient bleeding was higher in Hispanic patients with a higher likelihood of receiving appropriate prophylaxis (OR 1.94, CI:1.16-3.32) and NHOR patients with a lower likelihood (OR 1.90, CI:1.10-3.36) CONCLUSION: Postoperative VTE was similar for minority patients receiving appropriate prophylaxis, compared to NHW patients. Inpatient bleeding was more likely in Hispanic and NHOR patients but may not be related to receiving appropriate prophylaxis. NHOR patients were less likely to receive inpatient thromboprophylaxis.
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Affiliation(s)
- Michael A Edwards
- Mayo Clinic, Department of Surgery, Division of Advanced GI and Bariatric Surgery, Jacksonville, FL, 32224, USA.
| | - Mark Falstin
- Mayo Clinic, Department of Surgery, Division of Advanced GI and Bariatric Surgery, Jacksonville, FL, 32224, USA
| | - Akash Uddandam
- McMaster University, Department of Health Sciences, Hamilton, Ontario, L8S 4L8, Canada
| | - Emily Brennan
- Mayo Clinic, Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Jacksonville, FL, 32224, USA
| | - Aaron Spaulding
- Mayo Clinic, Robert D. and Patricia E. Kern Center, Division of Health Care Delivery Research, Jacksonville, FL, 32224, USA
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Abella MKIL, Thorne T, Hayashi J, Finlay AK, Frick S, Amanatullah DF. An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes. Orthopedics 2024; 47:e131-e138. [PMID: 38285555 DOI: 10.3928/01477447-20240122-01] [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] [Indexed: 01/31/2024]
Abstract
BACKGROUND Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].
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Liu KC, Bagrodia N, Richardson MK, Piple AS, Kusnezov N, Wang JC, Lieberman JR, Heckmann ND. Risk Factors Associated with Thromboembolic Complications After total Hip Arthroplasty: An Analysis of 1,129 Pulmonary Emboli. J Am Acad Orthop Surg 2024:00124635-990000000-00928. [PMID: 38626438 DOI: 10.5435/jaaos-d-23-01213] [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: 12/14/2023] [Accepted: 02/28/2024] [Indexed: 04/18/2024] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) remains a dangerous complication after total hip arthroplasty (THA), despite advances in chemoprophylactic measures. This study aimed to identify risk factors of developing pulmonary embolism (PE) and deep vein thrombosis (DVT) after THA using a modern cohort of patients reflecting contemporary practices. METHODS The Premier Healthcare Database was queried for primary, elective THAs from January 1st, 2015, to December 31st, 2021. Patients who developed PE or DVT within 90 days of THA were compared with patients who did not develop any postoperative VTE. Differences in patient demographics, comorbidities, hospital factors, perioperative medications, chemoprophylactic agents, and allogeneic blood transfusion were compared between cohorts. Multivariable logistic regression models were used to identify independent risk factors of PE and DVT. In total, 544,298 THAs were identified, of which 1,129 (0.21%) developed a PE and 1,799 (0.33%) developed a DVT. RESULTS Patients diagnosed with a PE had significantly higher rates of in-hospital death (2.6% vs 0.1%, P < 0.001) compared with those without a PE. Age (adjusted odds ratio: 1.02 per year, 95% confidence interval [CI]: 1.01 to 1.03) and Black race (aOR: 1.52, 95% CI: 1.24 to 1.87) were associated with an increased risk of PE. Comorbidities associated with increased risk of PE included chronic pulmonary disease (aOR: 1.58, 95% CI: 1.36 to 1.84), pulmonary hypertension (aOR: 2.06, 95% CI: 1.39 to 3.04), and history of VTE (aOR: 2.38, 95% CI: 1.98 to 2.86). Allogeneic blood transfusion (aOR: 2.40, 95% CI: 1.88 to 3.06) was also associated with an increased risk of PE while dexamethasone utilization was associated with a reduced risk (aOR: 0.83, 95% CI: 0.73 to 0.95). DISCUSSION Increasing age; Black race; allogeneic blood transfusion; and comorbidities, including chronic pulmonary disease, pulmonary hypertension, and history of VTE, were independent risk factors of PE after THA. Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen.
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Affiliation(s)
- Kevin C Liu
- From the Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
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Rechenmacher AJ, Case A, Wu M, Ryan SP, Seyler TM, Bolognesi MP. Outcome Disparities in Total Knee and Total Hip Arthroplasty among Native American Populations. J Racial Ethn Health Disparities 2024; 11:1106-1115. [PMID: 37036599 DOI: 10.1007/s40615-023-01590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/25/2023] [Accepted: 03/31/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities. METHODS This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses. RESULTS Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0). CONCLUSION AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study.
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Affiliation(s)
- Albert J Rechenmacher
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - Ayden Case
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Mark Wu
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA
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Sato EH, Stevenson KL, Blackburn BE, Peters CL, Archibeck MJ, Pelt CE, Gililland JM, Anderson LA. Impact of Demographic Variables on Recovery After Total Hip Arthroplasty. J Arthroplasty 2024; 39:721-726. [PMID: 37717829 DOI: 10.1016/j.arth.2023.09.012] [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: 01/20/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA. METHODS There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations. RESULTS Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002). CONCLUSIONS Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.
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Affiliation(s)
- Eleanor H Sato
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | | | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Race. J Arthroplasty 2024:S0883-5403(24)00072-X. [PMID: 38311298 DOI: 10.1016/j.arth.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Kaidi AC, Hammoor BT, Tyler WK, Geller JA, Cooper HJ, Hickernell TR. Is There an Implicit Racial Bias in the Case Order of Elective Total Joint Arthroplasty? J Racial Ethn Health Disparities 2024; 11:1-6. [PMID: 37095288 DOI: 10.1007/s40615-022-01492-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Identifying ways to improve equitable access to healthcare is of the utmost important. In this study, we analyzed whether patient race was negatively associated with surgical start times for total joint arthroplasties (TJA). METHODS The surgical case order and start times of all primary TJAs performed at a large academic medical center between May 2014 and May 2018 were retrospectively reviewed. Patients were included if > 21, had a documented self-reported race, and were operated on by an arthroplasty fellowship-trained surgeon. Operations were categorized as first-start, early (7:00 AM-11:00 AM), mid-day (11:00 AM-3:00 PM), or late (after 3:00 PM). Multivariable logistic regression (MLR) was performed, and odds ratios (OR) were calculated. RESULTS This study identified 1663 TJAs-871 total knee (TKA) and 792 total hip arthroplasties (THA) who met inclusion criteria. Overall, there was no association between race and surgical start time. Upon sub-analysis by surgical type, this held true for TKA patients, but self-identifying Hispanic and non-Hispanic Black patients undergoing THA were more likely to have later surgical start times (ORs: 2.08 and 1.88; p < 0.05). DISCUSSION Although there was no association between race and overall TJA surgical start times, patients with marginalized racial and ethnic identities were more likely to undergo elective THA later in the surgical day. Surgeons should be aware of potential implicit bias when determining case order to potentially prevent adverse outcomes due to staff fatigue or lack of proper resources later in the day.
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Affiliation(s)
- Austin C Kaidi
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, 622 W. 168th, PH-1110032, USA
| | - Bradley T Hammoor
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, 622 W. 168th, PH-1110032, USA
| | - Wakenda K Tyler
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, 622 W. 168th, PH-1110032, USA
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, 622 W. 168th, PH-1110032, USA
| | - H John Cooper
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, 622 W. 168th, PH-1110032, USA
| | - Thomas R Hickernell
- Department of Orthopaedic Surgery, Yale University, 260 Long Ridge Rd, CT, Stamford, United States.
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Hinman A, Chang R, Royse KE, Navarro R, Paxton E, Okike K. Utilization of Total Joint Arthroplasty by Rural-Urban Designation in Patients With Osteoarthritis in a Universal Coverage System. J Arthroplasty 2023; 38:2541-2548. [PMID: 37595769 DOI: 10.1016/j.arth.2023.08.030] [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: 01/26/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Utilization of total joint arthroplasty (TJA) is affected by differences linked to sex, race, and socioeconomic status; there is little information about how geographic variation contributes to these differences. We sought to determine whether discrepancies in TJA utilization exist in patients diagnosed with osteoarthritis (OA) based upon urban-rural designation in a universal coverage system. METHODS We conducted a cohort study using data from a US-integrated healthcare system (2015 to 2019). Patients aged ≥50 years who had a diagnosis of hip or knee OA were included. Total hip arthroplasty and total knee arthroplasty utilization (in respective OA cohorts) was evaluated by urban-rural designation (urban, mid, and rural). Incidence rate ratios (IRRs) for urban-rural regions were modeled using multivariable Poisson regressions. RESULTS The study cohort included 93,642 patients who have hip OA and 275,967 patients who had knee OA. In adjusted analysis, utilization of primary total hip arthroplasty was lower in patients living in urban areas (IRR = 0.87, 95% confidence interval = 0.81 to 0.94) compared to patients in rural regions. Similarly, total knee arthroplasty was used at a lower rate in urban areas (IRR = 0.88, 95% confidence interval = 0.82 to 0.95) compared with rural regions. We found no differences in the hip and knee groups within the mid-region. CONCLUSIONS In hip and knee OA patients enrolled in a universal coverage system, we found patients living in urban areas had lower TJA utilization compared to patients living in rural areas. Further research is needed to determine how patient location contributes to differences in elective TJA utilization. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adrian Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Richard Chang
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Kathryn E Royse
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Ronald Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, South Bay, California
| | - Elizabeth Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Kanu Okike
- Department of Orthopaedics, Hawaii Permanente Medical Group, Honolulu, Hawaii
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Rubinger L, Gazendam AM, Wood TJ. Marginalization Influences Access, Outcomes, and Discharge Destination Following Total Joint Arthroplasty in Canada's Universal Healthcare System. J Arthroplasty 2023; 38:2204-2209. [PMID: 37286053 DOI: 10.1016/j.arth.2023.05.075] [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: 11/19/2022] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes. METHODS This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores. RESULTS The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046). CONCLUSION Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Luc Rubinger
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aaron M Gazendam
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas J Wood
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada
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Hinman AD, Royse KE, Chan PH, Paxton EW, Navarro RA. Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population. J Arthroplasty 2023; 38:2210-2219.e1. [PMID: 37479196 DOI: 10.1016/j.arth.2023.07.012] [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: 10/27/2022] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations. METHODS Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression. RESULTS Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients. CONCLUSION Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Kathryn E Royse
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, South Bay, California
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Lung BE, Donnelly MR, Callan K, McLellan M, Taka T, Stitzlein RN, McMaster WC, So DH, Yang S. Preoperative demographics and laboratory markers may be associated with early dislocation after total hip arthroplasty. J Exp Orthop 2023; 10:100. [PMID: 37801165 PMCID: PMC10558409 DOI: 10.1186/s40634-023-00659-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE The purpose of this study was to identify modifiable medical comorbidities, laboratory markers and flaws in perioperative management that increase the risk of acute dislocation in total hip arthroplasty (THA) patients. METHODS All THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Demographic data, preoperative laboratory values, recorded past medical history, operative details as well as outcome and complication information were collected. The study population was divided into two cohorts: non-dislocation and dislocation patients. Statistics were performed to compare the characteristics of both cohorts and to identify risk factors for prosthetic dislocation (α < 0.05). RESULTS 275,107 patients underwent primary THA in 2007 to 2020, of which 1,258 (0.5%) patients experienced a prosthetic hip dislocation. Demographics between non-dislocation and dislocation cohorts varied significantly in that dislocation patients were more likely to be female, older, with lower body mass index and a more extensive past medical history (all p < 0.05). Moreover, hypoalbuminemia and moderate/severe anemia were associated with increased risk of dislocation in a multivariate model (all p < 0.05). Finally, use of general anesthesia, longer operative time, and longer length of hospital stay correlated with greater risk of prosthetic dislocation (all p < 0.05). CONCLUSIONS Elderly female patients and patients with certain abnormal preoperative laboratory values are at risk for sustaining acute dislocations after index THA. Careful interdisciplinary planning and medical optimization should be considered in high-risk patients as dislocations significantly increase the risk of sepsis, cerebral vascular accident, and blood transfusions on readmission.
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Affiliation(s)
- Brandon E Lung
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA.
| | - Megan R Donnelly
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Kylie Callan
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Maddison McLellan
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Taha Taka
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Russell N Stitzlein
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - William C McMaster
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - David H So
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
| | - Steven Yang
- Irvine School of Medicine, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA, 92868, USA
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Dhanjani SA, Schmerler J, Wenzel A, Gomez G, Oni J, Hegde V. Racial and Socioeconomic Disparities in Risk and Reason for Revision in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:e815-e823. [PMID: 37276485 DOI: 10.5435/jaaos-d-22-01124] [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: 11/23/2022] [Accepted: 04/11/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION Data regarding racial/ethnic and socioeconomic differences in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) have been inconsistent. This study examined racial/ethnic and socioeconomic disparities in comorbidity-adjusted risk and reason for rTHA and rTKA. METHODS Patients who underwent rTHA or rTKA between 2006 and 2014 in the National Inpatient Sample were identified. Multivariable logistic regression models adjusted for payer status, hospital geographic setting, and patient characteristics (age, sex, and Elixhauser Comorbidity Index) were used to examine the effect of race/ethnicity and socioeconomic status on trends in annual risk of rTHA/rTKA and causes of rTHA/rTKA. RESULTS Black patients were less likely to undergo rTHA and more likely to undergo rTKA while Hispanic patients were more likely to undergo rTHA and less likely to undergo rTKA ( P < 0.001 for all) compared with White patients. Patients residing in areas of lower income quartiles were more likely to undergo rTHA and rTKA compared with those in the highest quartile ( P < 0.001), and these disparities persisted and widened over time. Black, Hispanic, and Asian patients were less likely to undergo rTHA/rTKA because of dislocation compared with White patients ( P < 0.001 for all). Patients from areas of lower income quartiles were more likely to undergo rTHA because of septic complications and less likely to require both rTHA and rTKA because of mechanical complications ( P < 0.001 for all). DISCUSSION Racial/ethnic and socioeconomic disparities exist in risk and cause of rTHA and rTKA. Increasing awareness and a focus on minimizing variability in hospital quality may help mitigate these disparities.
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Affiliation(s)
- Suraj A Dhanjani
- From the Johns Hopkins University School of Medicine, Baltimore, MD (Dhanjani, Schmerler, and Gomez), and the Department of Orthopaedic Surgery, (Dr. Wenzel, Dr. Oni, Dr. Hegde), The Johns Hopkins University School of Medicine, Baltimore, MD (Wenzel, Oni, and Hegde)
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Teimouri M, Motififard M, Lalehzar SS, Shahsavan M, Khayam T, Taravati AM, Sadeghian A. Persistent pain following total knee arthroplasty: The role of underlying diseases. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:57. [PMID: 37496648 PMCID: PMC10366980 DOI: 10.4103/jrms.jrms_190_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/28/2023]
Abstract
Background With increasing age and joint-destructive diseases, the need for novel surgeries such as total knee arthroplasty (TKA) has increased. Complications such as pain exacerbation and persistent pain after surgery may occur which increases rehabilitation programs. Factors such as body mass index (BMI), psychiatric disorders, spine diseases, and comorbidities diseases can affect outcomes. Our study was conducted to evaluate the effect of BMI, psychiatric disorders, spine diseases, and underlying diseases on persistent and annoying pain after TKA. Materials and Methods This is a case-control study that was conducted on patients who underwent TKA in Kashani Hospital in Isfahan City in 2020-2022. Demographic data of patients including age and BMI, diabetes mellitus (DM), history of psychiatric disorders, spine disorders such as spondylolisthesis or disc herniation, and other underlying diseases were obtained. Patients were assigned to case or control groups based on pain complaints after surgery. All patients were evaluated 6 months after the initial surgery. After collecting the study data, they were entered into SPSS software (version 25, IBM Corporation, Armonk, NY, USA) and analyzed. Results We enrolled 35 patients in the case group and 39 patients in the control group between June 2020 and September 2022, based on the severity of pain measured using a Visual Analog Scale score. Our results show that BMI and DM had a meaningful relationship with pain after surgery (P ≤ 0.01). Other factors did not show a significant difference between groups. Conclusion Underlying diseases, psychiatric diseases, and spine disorders did not significantly affect the pain after TKA. Patients with DM and higher BMI experienced more persistent pain after TKA.
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Affiliation(s)
- Mehdi Teimouri
- Department of Orthopedic Surgery, School of Medicine, KashaniUniversity Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Motififard
- Department of Orthopedic Surgery, School of Medicine, KashaniUniversity Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sahar Sadat Lalehzar
- Department of Orthopedic Surgery, School of Medicine, KashaniUniversity Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Shahsavan
- Department of Orthopedic Surgery, School of Medicine, KashaniUniversity Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tala Khayam
- Department of Orthopedic Surgery, School of Medicine, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Mohammad Taravati
- Department of Orthopedic Surgery, School of Medicine, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhossein Sadeghian
- Department of Orthopedic Surgery, School of Medicine, Zabol University of Medical Sciences, Zabol, Sistan and Baluchestan Province, Iran
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Aggarwal VA, Sohn G, Walton S, Sambandam S, Wukich D. Complications and Costs Associated With Ethnicity Following Total Hip Arthroplasty: A Retrospective Matched Cohort Study. Cureus 2023; 15:e40595. [PMID: 37469826 PMCID: PMC10353834 DOI: 10.7759/cureus.40595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Minority patients often have greater numbers of complications, revisions, and costs after total hip arthroplasty (THA). This study investigates how race correlates with specific surgical complications, revisions, and total costs following THA both before and after propensity matching. METHODS Data from 2014-2016 were collected from a large commercial insurance database known as PearlDiver. THA patients were assigned under Current Procedural Terminology (CPT-27130) and International Statistical Classification of Diseases (ICD-9-P-8151) codes and then divided into groups based on racial status in the database. Patients of different ethnicities including White, Black, Asian, and Hispanic patients were compared in regard to age, gender, comorbidities, lengths of stay, and surgical complications and costs at thirty days, ninety days, and one year using unequal variance t-tests. Black, Asian, and Hispanic patients are collectively referred to as minority patients. Patient comparisons were done both before and after matching for age, gender, tobacco use, diabetes, and obesity comorbidities. RESULTS A total of 73,688 White (93%), 4,822 Black (6%), 268 Asian (0.3%), and 420 Hispanic (0.5%) THA patients were included. Significantly more minority patients underwent THA under the age of 65 and had higher comorbidity indices and lengths of stay. Black patients had significantly higher complication rates, but there was no significant difference in rates of revision in any minority group. Minority patients were charged 9%-83% more. After matching, Black and Hispanic patients maintained higher comorbidity indices and lengths of stay. Black patients had a spectrum of complication rates but significantly decreased revision rates. Furthermore, after matching, minority patients were charged 5%-65% more. CONCLUSIONS Black patients experienced significantly greater rates of complications and higher total costs; whereas, Asian and Hispanic patients did not have significant differences in complications but did have higher costs. Therefore, this study aligns with previous studies and supports our hypothesis that Black ethnicity patients have worse outcomes than White ethnicity patients after THA, advocating for reducing health disparities and establishing more equitable healthcare, but does not support our hypothesis for Asian and Hispanic patients, likely due to a small study population size, warranting further research into the topic.
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Affiliation(s)
- Vikram A Aggarwal
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Garrett Sohn
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Sharon Walton
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Senthil Sambandam
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Dane Wukich
- Orthopedics, University of Texas Southwestern Medical Center, Dallas, USA
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Engler ID, Vasavada KD, Vanneman ME, Schoenfeld AJ, Martin BI. Do Community-level Disadvantages Account for Racial Disparities in the Safety of Spine Surgery? A Large Database Study Based on Medicare Claims. Clin Orthop Relat Res 2023; 481:268-278. [PMID: 35976183 PMCID: PMC9831153 DOI: 10.1097/corr.0000000000002323] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Racial health disparities across orthopaedic surgery subspecialties, including spine surgery, are well established. However, the underlying causes of these disparities, particularly relating to social determinants of health, are not fully understood. QUESTIONS/PURPOSES (1) Is there a racial difference in 90-day mortality, readmission, and complication rates ("safety outcomes") among Medicare beneficiaries after spine surgery? (2) To what degree does the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), a community-level marker of social determinants of health, account for racial disparities in safety outcomes? METHODS To examine racial differences in 90-day mortality, readmission, and complications after spine surgery, we retrospectively identified all 419,533 Medicare beneficiaries aged 65 or older who underwent inpatient spine surgery from 2015 to 2019; we excluded 181,588 patients with endstage renal disease or Social Security disability insurance entitlements, who were on Medicare HMO, or who had missing SVI data. Because of the nearly universal coverage of those age 65 or older, Medicare data offer a large cohort that is broadly generalizable, provides improved precision for relatively rare safety outcomes, and is free of confounding from differential insurance access across races. The Master Beneficiary Summary File includes enrollees' self-reported race based on a restrictive list of mutually exclusive options. Even though this does not fully capture the entirety of racial diversity, it is self-reported by patients. Identification of spine surgery was based on five Diagnosis Related Groups labeled "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck, except fusion." Although heterogeneous, these cohorts do not reflect inherently different biology that would lead us to expect differences in safety outcomes by race. We report specific types of complications that did and did not involve readmission. Although complications vary in severity, we report them as composite measures while being cognizant of the inherent limitations of making inferences based on aggregate measures. The SVI was chosen as the mediating variable because it aggregates important social determinants of health and has been shown to be a marker of high risk of poor public health response to external stressors. Patients were categorized into three groups based on a ranking of the four SVI themes: socioeconomic status, household composition, minority status and language, and housing and transportation. We report the "average race effects" among Black patients compared with White patients using nearest-neighbor Mahalanobis matching by age, gender, comorbidities, and spine surgery type. Mahalanobis matching provided the best balance among propensity-type matching methods. Before matching, Black patients in Medicare undergoing spine surgery were disproportionately younger with more comorbidities and were less likely to undergo cervical fusion. To estimate the contribution of the SVI on racial disparities in safety outcomes, we report the average race effect between models with and without the addition of the four SVI themes. RESULTS After matching on age, gender, comorbidities, and spine surgery type, Black patients were on average more likely than White patients to be readmitted (difference of 1.5% [95% CI 0.9% to 2.1%]; p < 0.001) and have complications with (difference of 1.2% [95% CI 0.5% to 1.9%]; p = 0.002) or without readmission (difference of 3.6% [95% CI 2.9% to 4.3%]; p < 0.001). Adding the SVI to the model attenuated these differences, explaining 17% to 49% of the racial differences in safety, depending on the outcome. An observed higher rate of 90-day mortality among Black patients was explained entirely by matching using non-SVI patient demographics (difference of 0.00% [95% CI -0.3% to 0.3%]; p = 0.99). However, even after adjusting for the SVI, Black patients had more readmissions and complications. CONCLUSION Social disadvantage explains up to nearly 50% of the disparities in safety outcomes between Black and White Medicare patients after spine surgery. This argument highlights an important contribution of socioeconomic circumstances and societal barriers to achieving equal outcomes. But even after accounting for the SVI, there remained persistently unequal safety outcomes among Black patients compared with White patients, suggesting that other unmeasured factors contribute to the disparities. This is consistent with evidence documenting Black patients' disadvantages within a system of seemingly equal access and resources. Research on racial health disparities in orthopaedics should account for the SVI to avoid suggesting that race causes any observed differences in complications among patients when other factors related to social deprivation are more likely to be determinative. Focused social policies aiming to rectify structural disadvantages faced by disadvantaged communities may lead to a meaningful reduction in racial health disparities. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ian D. Engler
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Megan E. Vanneman
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Brook I. Martin
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
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Benes GA, Dasa V, Krause PC, Jones DG, Leslie LJ, Chapple AG. Disparities in Elective and Nonelective Total Hip Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00011-6. [PMID: 36690188 DOI: 10.1016/j.arth.2023.01.011] [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: 06/07/2022] [Revised: 12/21/2022] [Accepted: 01/15/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication. METHODS Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively. RESULTS After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation. CONCLUSION Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.
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Affiliation(s)
- Gregory A Benes
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Vinod Dasa
- LSUHSC Department of Orthopedic Surgery, New Orleans, Louisiana
| | - Peter C Krause
- LSUHSC Department of Orthopedic Surgery, New Orleans, Louisiana
| | - Deryk G Jones
- Ochsner Sports Medicine Institute, Jefferson, Louisiana
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Rudisill SS, Varady NH, Birir A, Goodman SM, Parks ML, Amen TB. Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis. J Arthroplasty 2023; 38:171-187.e18. [PMID: 35985539 DOI: 10.1016/j.arth.2022.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Samuel S Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Rush Medical College of Rush University, Chicago, Illinois
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Aseal Birir
- Harvard Medical School, Boston, Massachusetts
| | - Susan M Goodman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael L Parks
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Gressler LE, Devlin V, Jung M, Marinac-Dabic D, Sedrakyan A, Paxton EW, Franklin P, Navarro R, Ibrahim S, Forsberg J, Voorhorst PE, Zusterzeel R, Vitale M, Marks MC, Newton PO, Peat R. Orthopedic Coordinated Registry Network (Ortho-CRN): advanced infrastructure for real-world evidence generation. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 4:e000073. [PMID: 36393890 PMCID: PMC9660599 DOI: 10.1136/bmjsit-2020-000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 09/06/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laura Elisabeth Gressler
- Department of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Vincent Devlin
- Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mary Jung
- Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Danica Marinac-Dabic
- Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Elizabeth W Paxton
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California, USA
| | - Patricia Franklin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ronald Navarro
- Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California, USA
| | - Said Ibrahim
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Forsberg
- Department of Defense Osseointegration, Murtha Cancer Center, Bethesda, MD, USA
- Orthopaedic Oncology, Sibley Memorial Hospital, Johns Hopkins University, Washington, DC, USA
| | | | - Robbert Zusterzeel
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael Vitale
- Pediatric Spine and Scoliosis Service, Morgan Stanley Children's Hospital, New York, New York, USA
| | - Michelle C Marks
- Setting Scoliosis Straight Foundation, San Diego, California, USA
| | - Peter O Newton
- Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, California, USA
| | - Raquel Peat
- Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, Maryland, USA
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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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Grits D, Hecht CJ, Acuña AJ, Burkhart RJ, Kamath AF. Have all races experienced reductions in complication rates following total hip arthroplasty? A NSQIP analysis between 2011 and 2019. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03385-x. [PMID: 36114874 DOI: 10.1007/s00590-022-03385-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Despite numerous articles in the orthopedic literature evaluating racial and ethnic disparities, inequalities in total joint arthroplasty outcomes remain. While the National Surgical Quality Improvement (NSQIP) database has been previously utilized to highlight these disparities, no previous analysis has evaluated how the rate of various perioperative complications has changed over recent years when segregating by patient race. Specifically, we evaluated if all races have experienced decreases in (1) medical complications, (2) wound complications, (3) venous thromboembolism (VTE), and (4) readmission/reoperation rates following total hip arthroplasty (THA) over recent years? METHODS Current Procedural Terminology (CPT) code 27,130 (total hip arthroplasty) was utilized to identify all THA procedures conducted between 2011 and 2019. Patients were segregated according to race and various demographics were collected. Linear regression was utilized to evaluate changes in each complication rate between 2011 and 2019. A multivariate regression was then conducted for each complication to evaluate whether race independently was associated with each outcome. RESULTS Our analysis included a total of 212,091 patients undergoing primary THA. This included 182,681 (85.76%) White, 19,267 (9.04%) Black, 5928 (2.78%) Hispanic, and 4215 (1.98%) Asian patients. We found that for urinary tract infection (UTI), acute renal failure, superficial SSI, and readmission rates, White patients experienced significant reductions between 2011 and 2019. However, this was not consistent across all races. Black race was associated with a significantly increased risk of acute renal failure (OR: 2.03, 95% CI: 1.17-3.34; p = 0.008), renal insufficiency (OR: 2.33, 95% CI: 1.62-3.28; p < 0.001), deep vein thrombosis (DVT) (OR: 1.34, 95% CI: 1.07-1.66; p = 0.01), and pulmonary embolism (PE) (OR: 1.76, 95% CIL: 1.36-2.24; p < 0.001). CONCLUSION Our analysis highlights specific complications for which further interventions are necessary to reduce inequalities across races. These include medical optimization, increased patient education, and continued efforts at understanding how social factors may impact-related care inequalities. Future study is needed to evaluate specific interventions that can be applied at the health systems level to ensure all patients undergoing THA receive the highest quality of care regardless of race.
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Affiliation(s)
- Daniel Grits
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Robert J Burkhart
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.
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22
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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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23
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Upfill-Brown AM, Paisner ND, Donnelly PC, De A, Sassoon AA. Lower Rates of Ceramic Femoral Head Use in Non-White Patients in the United States, a National Registry Study. J Arthroplasty 2022; 37:S919-S924.e2. [PMID: 35307527 PMCID: PMC9386729 DOI: 10.1016/j.arth.2022.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of our study was to investigate the association of race and ethnicity with the use of the newest technology and postoperative outcomes in total hip arthroplasty (THA) using the American Academy of Orthopaedic Surgeons (AAOS) American Joint Replacement Registry (AJRR). METHODS Adult THA procedures were queried from the AJRR from 2012 to 2020. A mixed-effects multivariate regression model was used to evaluate the association of race and ethnicity with the use of the newest technology (ceramic femoral head, dual-mobility implant, and robotic assist) at 30-day, and 90-day readmission. A proportional subdistribution hazard model was used to model a risk of revision THA. RESULTS There were 85,188 THAs with complete data for an analysis of outcomes and 103,218 for an analysis of ceramic head usage. The median length of follow-up was 37.9 months (interquartile range [IQR] 21.6 to 56.3 months). In multivariate models, compared to White non-Hispanic patients, Black (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.92, P < .001), Hispanic (OR 0.76, CI 0.59-0.99, P = .037), Asian (OR 0.74, CI 0.55-1.00, P = .045), and Native American (OR 0.52, CI 0.30-0.87, P = .004) patients all had significantly lower rates of ceramic head use in THA. Compared to White non-Hispanic patients, Asian (hazard ratio [HR] 0.39, CI 0.18-0.86, P = .008) and Hispanic (HR 0.43, CI 0.19-0.98, P = .043) patients had significantly lower rates of revision. No differences in 30-day or 90-day readmission rates were seen. CONCLUSION Black, Hispanic, Native American, and Asian patients had lower rates of ceramic head use in THA when compared to White patients. These differences did not translate into worse clinical outcomes on a short-term follow-up. In fact, Asian patients had lower revision rates compared to non-Hispanic White patients. Additional study is necessary to evaluate the long-term consequence of lower ceramic head use in non-White patients in the United States.
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Affiliation(s)
| | - Noah D. Paisner
- Pacific Northwest University School of Health Sciences, Yakima, WA
| | - Patrick C. Donnelly
- American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL
| | - Ayushmita De
- American Joint Replacement Registry, American Academy of Orthopaedic Surgery, Rosemont, IL
| | - Adam A. Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA,Address correspondence to: Adam A. Sassoon, MD, MS, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th, Street, Suite 2100, Santa Monica, CA 90404
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24
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Okewunmi J, Mihalopoulos M, Huang HH, Mazumdar M, Galatz LM, Poeran J, Moucha CS. Racial Differences in Care and Outcomes After Total Hip and Knee Arthroplasties: Did the Comprehensive Care for Joint Replacement Program Make a Difference? J Bone Joint Surg Am 2022; 104:949-958. [PMID: 35648063 DOI: 10.2106/jbjs.21.00465] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is a paucity of literature on racial differences across a full total joint arthroplasty (TJA) "episode of care" and beyond. Given various incentives, the Comprehensive Care for Joint Replacement (CJR) program in the U.S. may have impacted preexisting racial differences across this care continuum. The purposes of the present study were (1) to assess trends in racial differences in care/outcome characteristics before, during, and after TJA surgery and (2) to assess if the CJR program coincided with reductions in these racial differences. METHODS This retrospective cohort study includes data on 1,483,221 TJAs (based on Medicare claims data, 2013 to 2018). Racial differences between Black and White patients were assessed for (1) preoperative characteristics (Deyo-Charlson comorbidity index, patient sex, and age), (2) characteristics during hospitalization (length of stay, blood transfusions, and combined complications), and (3) postoperative characteristics (90 and 180-day readmission rates and institutional post-acute care). Additionally, Medicare payments for each period were assessed. Racial differences (Black versus White patients) were expressed in terms of odds ratios (ORs) and 95% confidence intervals (CIs) per year. A "difference-in-differences" analysis (comparing before and after CJR implementation, with non-CJR hospitals being used as controls) estimated the association of the CJR program with changes in racial differences. RESULTS In both 2013 and 2018, Black patients (n = 74,390; 5.0%) were more likely than White patients to have a higher Deyo-Charlson comorbidity index (score of >0) (OR = 1.32 [95% CI = 1.28 to 1.36] and OR = 1.32 [95% CI = 1.28 to 1.37]), to require more transfusions (OR = 1.55 [95% CI = 1.49 to 1.62] and OR = 1.77 [95% CI = 1.56 to 2.01]), to be discharged to institutional post-acute care (OR = 1.40 [95% CI = 1.36 to 1.44] and OR = 1.49 [95% CI = 1.43 to 1.56]), and to be readmitted within 90 days (OR = 1.38 [95% CI = 1.32 to 1.44] and OR = 1.21 [95% CI = 1.13 to 1.29]) (p < 0.05 for all). Adjusted difference-in-differences analyses demonstrated that the CJR program coincided with reductions in racial differences in 90-day readmission (-1.24%; 95% CI, -2.46% to -0.03%) and 180-day readmission (-1.28%; 95% CI, -2.52% to -0.03%) (p = 0.044 for both). CONCLUSIONS Racial differences persist among patients managed with TJA. The CJR program coincided with reductions in some racial differences, thus identifying bundle design as a potential novel strategy to target racial disparities. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeffrey Okewunmi
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Meredith Mihalopoulos
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hsin-Hui Huang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.,Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Madhu Mazumdar
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Leesa M Galatz
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jashvant Poeran
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.,Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin S Moucha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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25
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Foroohar A, Prentice HA, Burfeind WE, Navarro RA, Mirzayan R, Zeltser DW. Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system. J Shoulder Elbow Surg 2022; 31:1242-1253. [PMID: 35093522 DOI: 10.1016/j.jse.2021.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included. METHODS Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk. RESULTS A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period. CONCLUSION This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.
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Affiliation(s)
- Abtin Foroohar
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | | | | | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | - Raffy Mirzayan
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, CA, USA
| | - David W Zeltser
- Department of Orthopedic Surgery, The Permanente Medical Group, San Francisco, CA, USA
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26
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Dlott CC, Wiznia DH. CORR Synthesis: How Might the Preoperative Management of Risk Factors Influence Healthcare Disparities in Total Joint Arthroplasty? Clin Orthop Relat Res 2022; 480:872-890. [PMID: 35302972 PMCID: PMC9029894 DOI: 10.1097/corr.0000000000002177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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27
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Cwalina TB, Jella TK, Manyak GA, Kuo A, Kamath AF. Is Our Science Representative? A Systematic Review of Racial and Ethnic Diversity in Orthopaedic Clinical Trials from 2000 to 2020. Clin Orthop Relat Res 2022; 480:848-858. [PMID: 34855650 PMCID: PMC9007212 DOI: 10.1097/corr.0000000000002050] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND A lack of racial and ethnic representation in clinical trials may limit the generalizability of the orthopaedic evidence base as it applies to patients in underrepresented minority populations and perpetuate existing disparities in use, complications, or functional outcomes. Although some commentators have implied the need for mandatory race or ethnicity reporting across all orthopaedic trials, the usefulness of race or ethnic reporting likely depends on the specific topic, prior evidence of disparities, and individualized study hypotheses. QUESTIONS/PURPOSES In a systematic review, we asked: (1) What proportion of orthopaedic clinical trials report race or ethnicity data, and of studies that do, how many report data regarding social covariates or genomic testing? (2) What trends and associations exist for racial and ethnic reporting among these trials between 2000 and 2020? (3) What is the racial or ethnic representation of United States trial participants compared with that reported in the United States Census? METHODS We performed a systematic review of randomized controlled trials with human participants published in three leading general-interest orthopaedic journals that focus on clinical research: The Journal of Bone and Joint Surgery, American Volume; Clinical Orthopaedics and Related Research; and Osteoarthritis and Cartilage. We searched the PubMed and Embase databases using the following inclusion criteria: English-language studies, human studies, randomized controlled trials, publication date from 2000 to 2020, and published in Clinical Orthopaedics and Related Research; The Journal of Bone and Joint Surgery, American Volume; or Osteoarthritis and Cartilage. Primary outcome measures included whether studies reported participant race or ethnicity, other social covariates (insurance status, housing or homelessness, education and literacy, transportation, income and employment, and food security and nutrition), and genomic testing. The secondary outcome measure was the racial and ethnic categorical distribution of the trial participants included in the studies reporting race or ethnicity. From our search, 1043 randomized controlled trials with 184,643 enrolled patients met the inclusion criteria. Among these studies, 21% (223 of 1043) had a small (< 50) sample size, 56% (581 of 1043) had a medium (50 to 200) sample size, and 23% (239 of 1043) had a large (> 200) sample size. Fourteen percent (141 of 1043) were based in the Northeast United States, 9.2% (96 of 1043) were in the Midwest, 4.7% (49 of 1043) were in the West, 7.2% (75 of 1043) were in the South, and 65% (682 of 1043) were outside the United States. We calculated the overall proportion of studies meeting the inclusion criteria that reported race or ethnicity. Then among the subset of studies reporting race or ethnicity, we determined the overall rate and distribution of social covariates and genomic testing reporting. We calculated the proportion of studies reporting race or ethnicity that also reported a difference in outcome by race or ethnicity. We calculated the proportion of studies reporting race or ethnicity by each year in the study period. We also calculated the proportions and 95% CIs of individual patients in each racial or ethnic category of the studies meeting the inclusion criteria. RESULTS During the study period (2000 to 2020), 8.5% (89 of 1043) of studies reported race or ethnicity. Of the trials reporting this factor, 4.5% (four of 89) reported insurance status, 15% (13 of 89) reported income, 4.5% (four of 89) reported housing or homelessness, 18% (16 of 89) reported education and literacy, 0% (0 of 89) reported transportation, and 2.2% (two of 89) reported food security or nutrition of trial participants. Seventy-eight percent (69 of 89) of trials reported no social covariates, while 22% (20 of 89) reported at least one. However, 0% (0 of 89) of trials reported genomic testing. Additionally, 5.6% (five of 89) of these trials reported a difference in outcomes by race or ethnicity. The proportion of studies reporting race or ethnicity increased, on average, by 0.6% annually (95% CI 0.2% to 1.0%; p = 0.02). After controlling for potentially confounding variables such as funding source, we found that studies with an increased sample size were more likely to report data by race or ethnicity; location in North America overall, Europe, Asia, and Australia or New Zealand (compared with the Northeast United States) were less likely to; and specialty-topic studies (compared with general orthopaedics research) were less likely to. Our sample of United States trials contained 18.9% more white participants than that reported in the United States Census (95% CI 18.4% to 19.4%; p < 0.001), 5.0% fewer Black participants (95% CI 4.6% to 5.3%; p < 0.001), 17.0% fewer Hispanic participants (95% CI 16.8% to 17.1%; p < 0.001), 5.3% fewer Asian participants (95% CI 5.2% to 5.4%; p < 0.001), and 7.5% more participants from other groups (95% CI 7.2% to 7.9%; p < 0.001). CONCLUSION Reporting of race or ethnicity data in orthopaedic clinical trials is low compared with other medical fields, although the proportion of diseases warranting this reporting might be lower in orthopaedics. CLINICAL RELEVANCE Investigators should initiate discussions about race and ethnicity reporting in the early stages of clinical trial development by surveying available published evidence for relevant health disparities, social determinants, and, when warranted, genomic risk factors. The decision to include or exclude race and ethnicity data in study protocols should be based on specific hypotheses, necessary statistical power, and an appreciation for unmeasured confounding. Future studies should evaluate cost-efficient mechanisms for obtaining baseline social covariate data and investigate researcher perspectives on current administrative workflows and decision-making algorithms for race and ethnicity reporting.
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Affiliation(s)
- Thomas B. Cwalina
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tarun K. Jella
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Grigory A. Manyak
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andy Kuo
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Atul F. Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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29
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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: 17] [Impact Index Per Article: 8.5] [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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31
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Brown M, Udawatta T, Flesch L, Strnad GJ, Briskin I, Jones M, Kaar S, Rosneck JT, Farrow LD. Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine–Related Hip Disabilities. Orthop J Sports Med 2022; 10:23259671211069944. [PMID: 35155706 PMCID: PMC8832614 DOI: 10.1177/23259671211069944] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine–related hip disabilities. Purpose: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. Results: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. Conclusion: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine–related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.
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Affiliation(s)
- Marsalis Brown
- Department of Orthopaedic Surgery, University Hospitals–Cleveland Medical Center, Cleveland, Ohio, USA
| | - Thiran Udawatta
- Department Orthopaedic Surgery, Saint Louis University, St Louis, Missouri, USA
| | - Lance Flesch
- Department Orthopaedic Surgery, Saint Louis University, St Louis, Missouri, USA
| | - Gregory J. Strnad
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Isaac Briskin
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Morgan Jones
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Sports Health, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott Kaar
- Department Orthopaedic Surgery, Saint Louis University, St Louis, Missouri, USA
| | - James T. Rosneck
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Sports Health, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lutul D. Farrow
- Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Sports Health, Cleveland Clinic, Cleveland, Ohio, USA
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Prentice HA, Chan PH, Royse KE, Hinman AD, Reddy NC, Paxton EW. Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty. J Arthroplasty 2022; 37:303-311. [PMID: 34718107 DOI: 10.1016/j.arth.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/11/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years. METHODS A Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years. RESULTS Patients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability. CONCLUSION Identified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Kathryn E Royse
- Surgical Outcomes & Analysis, Kaiser Permanente, San Diego, CA
| | - Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, CA
| | - Nithin C Reddy
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, CA
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Racial and Ethnic Disparities in Hip Fracture Surgery Care in the United States From 2006 to 2015: A Nationwide Trends Study. J Am Acad Orthop Surg 2022; 30:e182-e190. [PMID: 34520407 DOI: 10.5435/jaaos-d-21-00137] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/12/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in the surgical treatment of hip fractures have been previously reported, demonstrating delayed time to surgery and worse perioperative outcomes for minority patients. However, data are lacking on how these disparities have trended over time and whether national efforts have succeeded in reducing them. The aim of this study was to investigate temporal trends in racial and ethnic disparities in perioperative metrics for patients undergoing hip fracture surgery in the United States from 2006 to 2015. METHODS The National Inpatient Sample was queried for White, Black, Hispanic, and Asian patients who underwent hip fracture surgery between 2006 and 2015. Perioperative metrics, including delayed time to surgery (≥2 calendar days from admission to surgical intervention), length of stay (LOS), total inpatient complications, and mortality, were trended over time. Changes in racial and ethnic disparities were assessed using linear and logistic regression models. RESULTS During the study period, there were persistent disparities in delayed time to surgery for White versus Black, Hispanic, and Asian patients (eg, White versus Black: 30.1% versus 39.7% in 2006 and 22% versus 28.8% in 2015, Ptrend> 0.05 for all). Although disparities in total LOS remained consistent for White versus Black patients (Ptrend= 0.97), these disparities improved for White versus Hispanic and Asian patients (eg, White versus Hispanic: 4.8 days versus 5.3 in 2006 and 4.1 days versus 4.4 in 2015, Ptrend < 0.05 for both). DISCUSSION Racial and ethnic disparities were persistent in time to surgery and discharge disposition for hip fracture surgery between White and minority patients from 2006 to 2015 in the United States. These disparities particularly affected Black patients. Although there were encouraging signs of improving disparities in the LOS, these findings highlight the need for renewed orthopaedic initiatives and healthcare reform policies aimed at reducing perioperative disparities in orthopaedic trauma care.
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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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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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Reporting and Analyzing Demographics in the Journal of Arthroplasty: Are We Making Progress? J Arthroplasty 2021; 36:3825-3830. [PMID: 34597772 DOI: 10.1016/j.arth.2021.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/23/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Demographic factors, including age, sex, body mass index (BMI), race, and ethnicity have great effects on the outcomes of patients undergoing total joint arthroplasty. A portion of this data is included in nearly every study, but the completeness with which it is reported is variable. The purpose of this study is to investigate the frequency at which demographic information is reported and analyzed through formal statistical methods in randomized controlled trials (RCTs) published in the Journal of Arthroplasty (JOA). METHODS A systematic review was conducted of RCTs published in JOA between 2015 and 2019. For each study, we determined if age, sex, weight, height, BMI, race, and ethnicity were reported and/or analyzed. The overall frequency was assessed, along with the rates of reporting by individual year. Studies were evaluated using Cochrane risk-of-bias tool. RESULTS Age (96.7%), sex (96.7%), and BMI (80.4%) were reported by the majority of studies. There was very little information provided regarding race (6.2%) and ethnicity (3.8%); although both were reported at the highest frequency in 2019, the final year of articles reviewed. Sex was the most frequently analyzed variable at 11.5%. Only 1 study (0.5%) analyzed ethnicity and no studies analyzed race. CONCLUSION Although age, sex, and BMI are reported at a high rate, RCTs published in JOA rarely reported information on patient race and ethnicity. Demographics were infrequently included as part of statistical analysis. The importance of this information should be recognized and included in the analysis and interpretation of future studies.
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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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Comparison of Area Deprivation Index, Socioeconomic Parameters, and Preoperative Demographics With Postoperative Emergency Department Visits After Total Knee Arthroplasty. J Arthroplasty 2021; 36:2788-2794. [PMID: 33902984 DOI: 10.1016/j.arth.2021.03.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aims to determine if socioeconomic (SE) parameters, primarily area deprivation index (ADI), relate to postoperative emergency department (ED) visits after total knee arthroplasty (TKA). METHODS We retrospectively reviewed 2655 patients who underwent TKA in a health system of 4 hospitals. The primary outcome was an ED visit within 90 days, which was divided into those with and without readmission. SE parameters including ADI as well as preoperative demographics were analyzed. Univariable and multiple logistic regressions were performed determining risk of 90-day postoperative ED visits, as well as once in the ED, risks for readmission. RESULTS 436 patients (16.4%) presented to the ED within 90 days. ADI was not a risk factor. The multiple logistic regression demonstrated men, Medicare or Medicaid, and preoperative ED visits were consistently risk factors for a postoperative ED visit with and without readmission. Preoperative anticoagulation was only a risk factor for ED visits with readmission. Among patients who visited the ED, if the patient was Caucasian, a lower BMI, or higher American Society of Anesthesiologists score, they were likely to be readmitted. CONCLUSION The study demonstrated that the percentage of early ED returns after TKA was high and that ADI was not a predictor for 90-day postoperative ED visit. The only SE factor that may contribute to this phenomenon was insurance type. Once in the ED, race, preoperative ED visits, preoperative anticoagulation, BMI, gender, and preoperative American Society of Anesthesiologists score contributed to a risk of readmission. The study supports hospitals' mission to provide equal access health care.
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Lawler C, Gu L, Howard LE, Branche B, Wiggins E, Srinivasan A, Foster ML, Klaassen Z, De Hoedt AM, Gingrich JR, Theodorescu D, Freedland SJ, Williams SB. The impact of the social construct of race on outcomes among bacille Calmette-Guérin-treated patients with high-risk non-muscle-invasive bladder cancer in an equal-access setting. Cancer 2021; 127:3998-4005. [PMID: 34237155 DOI: 10.1002/cncr.33792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/24/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The objective of this study was to describe bladder cancer outcomes as a function of race among patients with high-risk non-muscle-invasive bladder cancer (NMIBC) in an equal-access setting. METHODS A total of 412 patients with high-risk NMIBC who received bacille Calmette-Guérin (BCG) from January 1, 2010, to December 31, 2015, were assessed. The authors used the Kaplan-Meier method to estimate event-free survival and Cox regression to determine the association between race and recurrence, progression, disease-specific, and overall survival outcomes. RESULTS A total of 372 patients who had complete data were included in the analysis; 48 (13%) and 324 (87%) were Black and White, respectively. There was no difference in age, sex, smoking status, or Charlson Comorbidity Index by race. White patients had a higher socioeconomic status with a greater percentage of patients living above the poverty level in comparison with Black patients (median, 85% vs 77%; P < .001). A total of 360 patients (97%) received adequate induction BCG, and 145 patients (39%) received adequate maintenance BCG therapy. There was no significant difference in rates of adequate induction or maintenance BCG therapy according to race. There was no significant difference in recurrence (hazard ratio [HR], 1.53; 95% confidence interval [CI], 0.64-3.63), progression (HR, 0.77; 95% CI, 0.33-1.82), bladder cancer-specific survival (HR, 1.01; 95% CI, 0.30-3.46), or overall survival (HR, 0.97; 95% CI, 0.56-1.66) according to Black race versus White race. CONCLUSIONS In this small study from an equal-access setting, there was no difference in the receipt of BCG or any differences in bladder cancer outcomes according to race.
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Affiliation(s)
- Corinne Lawler
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Lin Gu
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Biostatistics Shared Resource, Duke Cancer Institute, Durham, North Carolina
| | - Lauren E Howard
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Biostatistics Shared Resource, Duke Cancer Institute, Durham, North Carolina
| | - Brandee Branche
- Department of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Emily Wiggins
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Aditya Srinivasan
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of Urology, The University of Texas Medical Branch, Galveston, Texas
| | - Meagan L Foster
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Augusta University-Medical College of Georgia, Augusta, Georgia
| | - Amanda M De Hoedt
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Jeffrey R Gingrich
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Dan Theodorescu
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephen J Freedland
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Center for Integrated Research on Cancer and Lifestyle, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephen B Williams
- Department of Surgery, Durham Veterans Affairs Health Care System, Durham, North Carolina.,Division of Urology, The University of Texas Medical Branch, Galveston, Texas
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Ngarmukos S, Kim KI, Wongsak S, Chotanaphuti T, Inaba Y, Chen CF, Liu D. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors. Knee Surg Relat Res 2021; 33:18. [PMID: 34147134 PMCID: PMC8214263 DOI: 10.1186/s43019-021-00099-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Srihatach Ngarmukos
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu Seoul, Seoul, 134-727, Korea. .,Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea.
| | - Siwadol Wongsak
- Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanainit Chotanaphuti
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Liu
- Gold Coast Centre for Bone & Joint Surgery, Gold Coast, Australia
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Comorbidity Burden Contributing to Racial Disparities in Outpatient Versus Inpatient Total Knee Arthroplasty. J Am Acad Orthop Surg 2021; 29:537-543. [PMID: 33720079 DOI: 10.5435/jaaos-d-20-01038] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/10/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA. METHODS This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes. RESULTS A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery. DISCUSSION Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.
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Does racial background influence outcomes following total joint arthroplasty? J Clin Orthop Trauma 2021; 19:139-146. [PMID: 34099973 PMCID: PMC8167263 DOI: 10.1016/j.jcot.2021.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/16/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The purpose of this study is to assess whether racial differences influence patient-reported outcome measures (PROMs) following primary total hip (THA) and knee (TKA) arthroplasty. METHODS We retrospectively reviewed patients who underwent primary THA or TKA from 2016 to 2020 with available PROMs. Both THA and TKA patients were separated into three groups based on their ethnicity: Caucasian, African-American, and other races. Patient demographics, clinical data, and PROMs at various time-periods were collected and compared. Demographic differences were assessed using chi-square and ANOVA. Univariate ANCOVA was utilized to compare outcomes and PROMs while accounting for demographic differences. RESULTS This study included 1999 THA patients and 1375 TKA patients. In the THA cohort, 1636 (82%) were Caucasian, 177 (9%) were African-American, and 186 (9%) were of other races. In the TKA cohort, 864 (63%) were Caucasian, 236 (17%) were African-American, and 275 (20%) were of other races. Surgical-time significantly differed between the groups that underwent THA (88.4vs.100.5vs.96.1; p < 0.001) with African-Americans requiring the longest operative time. Length-of-stay significantly differed in both THA (1.5vs.1.9vs.1.8; p < 0.001) and TKA (2.1vs.2.5vs.2.3; p < 0.001) cohorts, with African-Americans having the longest stay. Caucasians reported significantly higher PROM scores compared to non-Caucasians in both cohorts. All-cause emergency-department (ED) visits, 90-day postoperative events (readmissions&revisions), and discharge-disposition did not statistically differ in both cohorts. CONCLUSION Non-Caucasian patients demonstrated lower PROM scores when compared to Caucasian patients following TJA although the differences may not be clinically relevant. LOS was significantly longer for African-Americans in both THA and TKA cohorts. Further investigation identifying racial disparity interventions is warranted. LEVEL OF EVIDENCE Prognostic Level III.
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Klemt C, Walker P, Padmanabha A, Tirumala V, Xiong L, Kwon YM. Minority Race and Ethnicity is Associated With Higher Complication Rates After Revision Surgery for Failed Total Hip and Knee Joint Arthroplasty. J Arthroplasty 2021; 36:1393-1400. [PMID: 33190994 DOI: 10.1016/j.arth.2020.10.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in access to hip and knee total joint arthroplasty (TJA) and postoperative outcomes have wide-reaching implications for patients and the health care system. The aim of this study is to evaluate the effect of ethnicity on clinical outcomes and complications following revision hip and knee TJA. METHODS A single-institution, retrospective analysis of a consecutive series of 4424 revision hip and knee TJA patients was evaluated. Student's t-test and chi-squared analysis were used to identify significant differences in patient demographics and clinical outcomes between Caucasians and various ethnic minorities, including African Americans, Hispanics, and Asians. RESULTS When compared with white patients, African American patients demonstrated a significantly higher BMI (P = .04), ASA score (P = .04), length of hospital stay (P = .06), and postoperative infection rates (P = .04). Hispanics demonstrated a significantly higher BMI (P = .04), when compared with white patients, alongside a significantly higher risk for postoperative infection (P < .01). African American demonstrated a significantly higher ASA score (P = .02; P = .03), when compared with Hispanics and Asians, alongside a significantly increased length of stay (P = .01) and higher risk for postoperative infection (P = .02). CONCLUSION The study findings demonstrate an underutilization of revision TJA by ethnic minority groups, suggesting that disparities in access to orthopedic surgery increase from primary to revision surgery despite higher failure rates of minority ethnic groups reported after primary TJA surgery. In addition, inferior postoperative outcomes were associated with African Americans and Hispanics, when compared to white patients, with African Americans demonstrating the highest risk of postoperative complications.
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Affiliation(s)
- Christian Klemt
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paul Walker
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anand Padmanabha
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Venkatsaiakhil Tirumala
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Liang Xiong
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Salomon B, Krause PC, Dasa V, Shi L, Jones D, Chapple AG. The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas. Arthroplast Today 2021; 7:200-207. [PMID: 33553550 PMCID: PMC7856322 DOI: 10.1016/j.artd.2020.12.016] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/22/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Background Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA. Methods Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year. Results Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA. Conclusion Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.
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Affiliation(s)
- Brett Salomon
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Deryk Jones
- Department of Orthopaedic Surgery, Section of Sports Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Andrew G Chapple
- Department of Public Health and Biostatistics, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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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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Li LT, Bokshan SL, McGlone PJ, Owens BD. Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015. Orthop J Sports Med 2020; 8:2325967120964473. [PMID: 33283006 PMCID: PMC7682220 DOI: 10.1177/2325967120964473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients. Hypothesis We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients. Study Design Descriptive epidemiology study. Methods This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity. Results A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001). Conclusion Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.
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Affiliation(s)
- Lambert T Li
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Steven L Bokshan
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Patrick J McGlone
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Ezomo OT, Sun D, Gronbeck C, Harrington MA, Halawi MJ. Where Do We Stand Today on Racial and Ethnic Health Disparities? An Analysis of Primary Total Hip Arthroplasty From a 2011-2017 National Database. Arthroplast Today 2020; 6:872-876. [PMID: 33163602 PMCID: PMC7609456 DOI: 10.1016/j.artd.2020.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/11/2020] [Accepted: 10/04/2020] [Indexed: 12/20/2022] Open
Abstract
Background Little is known about the persistence of health disparities in joint arthroplasty. The objective of this study was to update our knowledge on the state of racial and ethnic disparities in total hip arthroplasty (THA). Methods Patients undergoing primary, elective THA using the 2011-2017 American College of Surgeons National Surgical Quality Improvement Program were retrospectively reviewed. Five minority groups (non-Hispanic black or African American, Hispanic or Latino, Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander) were compared with non-Hispanic whites. The primary outcomes were in the differences in demographic characteristics, comorbidities, perioperative characteristics, THA utilization, length of stay (LOS), and 30-day adverse events (mortality, readmission, reoperation, and complications). Results A total of 155,870 patients were identified with racial and ethnic data available on 134,961 (86.6%) of them. Non-Hispanic white patients comprised 74.5% of all THA procedures. Except for Asians, all minority groups were more likely to be younger, have a higher body mass index, and smoke tobacco (P < .001). There were higher rates of nonprimary osteoarthritis, procedure length exceeding 100 minutes, and comorbidities among all minority groups. All minority groups, except Asian and Hawaiians or Pacific Islanders, were more likely to require an LOS >2 days. Blacks were more likely to develop surgical or medical complications (odds ratio [OR]: 1.21 and 1.2, respectively), whereas Hispanics or Latinos were more likely to develop surgical complications (OR: 1.28). American Indians or Alaska Natives were more likely to undergo reoperations (OR: 1.91). Conclusions Health disparities persist among minority groups with respect to comorbidities, THA utilization, LOS, and complications. Blacks and Hispanics or Latinos appear to be the most impacted by these disparities.
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Affiliation(s)
- Olohirere T Ezomo
- The Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Daniel Sun
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
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48
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Affiliation(s)
- Mengnai Li
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Gronbeck C, Cusano A, Cardenas JM, Harrington MA, Halawi MJ. Primary Total Hip Arthroplasty in Hispanic/Latino Patients: An Updated Nationwide Analysis of Length of Stay, 30-Day Outcomes, and Risk Factors. Arthroplast Today 2020; 6:721-725. [PMID: 32923557 PMCID: PMC7475048 DOI: 10.1016/j.artd.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background This study explored recent time trends in length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) pertaining to total hip arthroplasty in the Hispanic and Latino population. Methods A total of 4107 Hispanic and Latino patients who underwent primary total hip arthroplasty between 2011 and 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Annual trends in LOS and 30-day outcomes (readmission, reoperation, complications, and mortality) were calculated using univariate mixed-effect regression analyses. Risk factors for AEs were determined using multivariate analyses. Results Between 2011 and 2017, there was a significant reduction in LOS >2 midnights (67.6% to 29.5%, P < .001) among Hispanic patients, which was similar to that among non-Hispanic white patients and was also accompanied with improvements in comorbidity profiles and shorter operative times. Postoperatively, the annual rates of 30-day outcomes were comparable with those of white patients (P > .05). Chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use were the strongest independent predictors for AEs. Conclusions In the context of historically lower arthroplasty outcomes among the Hispanic and Latino population, current evidence suggests a receding tide, with annual trends showing significantly shorter LOS and comparable overall 30-day outcomes with whites. Patients with chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use are at the highest risk for developing 30-day AEs.
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Affiliation(s)
| | - Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Justin M Cardenas
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
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50
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Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans. J Arthroplasty 2020; 35:2357-2362. [PMID: 32498969 DOI: 10.1016/j.arth.2020.04.095] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/16/2020] [Accepted: 04/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients. METHODS Patients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient's neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery. RESULTS On multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty. CONCLUSION Minority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.
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