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Scuderi GR, Abdo ZE, Delanois RE, Mont MA. Will Socioeconomic Status Always Continue to Impact the Outcomes in Total Joint Arthroplasty? J Arthroplasty 2024; 39:2156-2157. [PMID: 39129148 DOI: 10.1016/j.arth.2024.07.021] [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] [Indexed: 08/13/2024] Open
MESH Headings
- Humans
- Social Class
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Hip/economics
- Treatment Outcome
- Arthroplasty, Replacement/economics
- Arthroplasty, Replacement/statistics & numerical data
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
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Paul RW, Osman A, Nigro A, Muchintala R, Destine H, Tjoumakaris FP, Freedman KB. The effects of social determinants of health on rotator cuff repair utilization and outcomes: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:346-352. [PMID: 39157253 PMCID: PMC11329048 DOI: 10.1016/j.xrrt.2024.03.015] [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] [Indexed: 08/20/2024]
Abstract
Background Since various social determinants of health (SDOH) have the potential to impact the utilization and postoperative outcomes of rotator cuff repair (RCR), a review of the literature is warranted. Therefore, the purpose of this systematic review was to evaluate the effects of SDOH on RCR utilization and postoperative outcomes in order to recognize external factors that may influence patients' access to RCR and optimal clinical outcomes. Methods Search terms related to RCR, utilization, outcomes, and SDOH were used to identify studies that reported associations between any SDOH (as defined by the World Health Organization) and RCR utilization, access, cost, or postoperative outcomes. Articles that did not isolate RCR or did not evaluate an SDOH were excluded. Nonrandomized studies were evaluated for study quality using the Methodological Index for Nonrandomized Studies score. Due to the heterogeneity of the reported data, only qualitative analysis was possible. Results Overall, 842 articles were considered for inclusion and 14 studies were included in qualitative analysis. The average Methodological Index for Nonrandomized Studies score of included studies was 14.1 ± 5.0. The SDOH most frequently evaluated were insurance status and race/ethnicity. Non-White race is associated with lower odds of surgery and physical therapy (PT) utilization, as well as delayed treatment. Similarly, public insurance is associated with lower PT and surgery utilization rates and decreased acceptance for postoperative PT. Postoperatively, public insurance is associated with worse patient-reported outcome scores and lower return to work rates. Conclusion Various SDOH can influence access, utilization, and outcomes of RCR. Orthopedic surgeons should be aware of how factors of race and insurance type can influence a patient's treatment and recovery after RCR.
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Affiliation(s)
- Ryan W. Paul
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Alim Osman
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Rahul Muchintala
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Henson Destine
- Division of Sports Medicine, Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Fotios P. Tjoumakaris
- Division of Sports Medicine, Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Kevin B. Freedman
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Bonsel JM, Kodali H, Poeran J, Bonsel GJ. Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty. Anesth Analg 2024:00000539-990000000-00873. [PMID: 39042570 DOI: 10.1213/ane.0000000000007107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. METHODS This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. CONCLUSIONS Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.
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Affiliation(s)
- Joshua M Bonsel
- From the Department of Orthopedics and Sports Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanish Kodali
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Jashvant Poeran
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
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Dhital R, Singh NC, Spiker AM, Poudel DR, Pedersen B, Bartels CM. Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis. Semin Arthritis Rheum 2024; 66:152444. [PMID: 38604118 DOI: 10.1016/j.semarthrit.2024.152444] [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: 01/02/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). METHODS This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). RESULTS Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. CONCLUSION We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.
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Affiliation(s)
- Rashmi Dhital
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA.
| | - Neha Chiruvolu Singh
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Dilli Ram Poudel
- Department of Medicine, Indiana Regional Medical Center, Indiana, PA
| | - Brian Pedersen
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Christie M Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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Kim H, Hart KD, Senders A, Schabel K, Ibrahim SA. Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups. Popul Health Manag 2024; 27:128-136. [PMID: 38442304 DOI: 10.1089/pop.2023.0310] [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] [Indexed: 03/07/2024] Open
Abstract
Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kyle D Hart
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Angela Senders
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn Schabel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon, USA
| | - Said A Ibrahim
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, USA
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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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Ghomrawi HMK, Golladay GJ, Riddle DL. A Proposed Conceptual Framework for Patient Selection for Knee Arthroplasty. J Bone Joint Surg Am 2024:00004623-990000000-01032. [PMID: 38442197 DOI: 10.2106/jbjs.23.00596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Hassan M K Ghomrawi
- Departments of Surgery, Medicine (Rheumatology), and Pediatrics, and Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, Virginia
| | - Daniel L Riddle
- Departments of Physical Therapy, Orthopaedic Surgery, and Rheumatology, Virginia Commonwealth University, Richmond, Virginia
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Kazerooni R, Healy S, Verduzco-Gutierrez M. Disparities in Access to Spasticity Chemodenervation Specialists in the United States: A Retrospective Cross-Sectional Study. Am J Phys Med Rehabil 2024; 103:203-207. [PMID: 38014884 DOI: 10.1097/phm.0000000000002375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The aim of the study is to explore variations in access to spasticity chemodenervation specialists across several geographical, ethnic, racial, and population density factors. DESIGN This is a retrospective cross-sectional study on Medicare Provider Utilization and Payment Data. Providers with substantial adult spasticity chemodenervation practices were included. Ratios were assessed across geographical regions as well as hospital referral regions. A multivariate linear regression model for the top 100 hospital referral regions by beneficiary population was created, using backward stepwise selection to eliminate variables with P values > 0.10 from final model. RESULTS A total of 566 providers with spasticity chemodenervation practices were included. Unadjusted results showed lower access in nonurban versus urban areas in the form of higher patient:provider ratios (83,106 vs. 51,897). Access was also lower in areas with ≥25% Hispanic populations (141,800 vs. 58,600). Multivariate linear regression results showed similar findings with urban hospital referral regions having significantly lower ratios (-45,764 [ P = 0.004] vs. nonurban) and areas with ≥25% Hispanic populations having significantly higher ratios (+96,249 [ P = 0.003] vs. <25% Hispanic areas). CONCLUSIONS Patients in nonurban and highly Hispanic communities face inequities in access to chemodenervation specialists. The Medicare data set analyzed only includes 12% of the US patient population; however, this elderly national cross-sectional cohort represents a saturated share of patients needing access to spasticity chemodenervation therapy. Future studies should venture to confirm whether findings are limited to this specialization, and strategies to improve access for these underserved communities should be explored.
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Affiliation(s)
- Rashid Kazerooni
- From the Merz Pharmaceuticals, LLC, Raleigh, North Carolina (RK); Department of Family and Community Medicine Residency Program, Mercy Health-Anderson Hospital, Cincinnati, Ohio (SH); and Department of Rehabilitation Medicine, Joe R. and Teresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, Texas (MV-G)
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Danielson EC, Li W, Suleiman L, Franklin PD. Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy. Health Serv Res 2024; 59:e14215. [PMID: 37605376 PMCID: PMC10771904 DOI: 10.1111/1475-6773.14215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
OBJECTIVE To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model. DATA SOURCES AND STUDY SETTING Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention. STUDY DESIGN This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015. DATA COLLECTION/EXTRACTION METHODS Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded. PRINCIPAL FINDINGS After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function. CONCLUSIONS We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.
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Affiliation(s)
- Elizabeth C. Danielson
- Department of Medical Social SciencesNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Wenjun Li
- Department of Public Health, Center for Health Statistics and Biostatistics Core, Health Statistics and Geography LabUniversity of MassachusettsLowellMassachusettsUSA
| | - Linda Suleiman
- Department of Orthopaedic SurgeryNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Patricia D. Franklin
- Department of Medical Social SciencesNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
- Department of Orthopaedic SurgeryNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Marcus-Aiyeku U, Fake P, Fetzer C, Hessels A, Kilpatrick R, Markiewicz D, McNicholas M, Mills K, Nedumalayil S, Paliwal M, Panten A, Schuld C, Ullero A. Utilization of patient-reported outcomes in joint replacement care design. Nurs Manag (Harrow) 2024; 55:42-50. [PMID: 38314996 DOI: 10.1097/nmg.0000000000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Analysis finds health disparities among the elective surgery population.
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Affiliation(s)
- Ulanda Marcus-Aiyeku
- Ulanda Marcus-Aiyeku is a nurse scientist at the Ann May Center, Hackensack Meridian Health in Edison, N.J. Pamela Fake is a staff RN at Hackensack University Medical Center in Hackensack, N.J. Christine Fetzer is a retired occupational therapist located in N.J. Amanda Hessels is a nurse scientist at the Ann May Center, Hackensack Meridian Health in Edison, N.J. and an assistant professor of nursing at Columbia University in New York, N.Y. Rachel Kilpatrick is the clinical program manager at Riverview Medical Center in Red Bank, N.J. Dorothy Markiewicz is a staff RN at Hackensack University Medical Center in Hackensack, N.J. Miriam McNicholas is the director of professional practice/clinical policy at Hackensack Meridian Health in Edison, N.J. Kimberly Mills is a project manager, Orthopedic-Care Transformation Services, Hackensack Meridian Health in Edison, N.J. Seera Nedumalayil is a staff RN at Hackensack University Medical Center in Hackensack, N.J. Mani Paliwal is a senior biostatistician at the Institute for Evidence Based Care, Hackensack Meridian Health in Edison, N.J. Angie Panten is a clinical program manager at Ocean University Medical Center in Brick Township, N.J. Clare Schuld is a clinical nurse navigator for Orthopedics at Old Bridge Medical Center in Old Bridge, N.J., and Raritan Bay Medical Center in Raritan, N.J. Amarlyn Ullero is a staff RN at Hackensack University Medical Center in Hackensack, N.J
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Rullán PJ, Emara AK, Zhou G, Pasqualini I, Klika AK, Koroukian S, Barsoum WK, Piuzzi NS. National Inpatient Datasets May No Longer Be Appropriate for Overall Total Hip and Knee Arthroplasties Projections after Removal from Inpatient-Only Lists. J Knee Surg 2024; 37:214-219. [PMID: 36807103 DOI: 10.1055/a-2037-6323] [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: 02/23/2023]
Abstract
It is unknown if the National Inpatient Sample (NIS) remains suitable to conduct projections for total knee arthroplasty (TKA) and total hip arthroplasty (THA), after their removal from "inpatient-only lists" in 2018 and 2020, respectively. We aimed to: (1) quantify primary THA and TKA volume from 2008 to 2018; (2) project estimates of future volume of THA and TKA until 2050; and (3) compare projections based on NIS data from 2008 to 2018 and 2008 to 2017, respectively. We identified all primary THA and TKA performed from 2008 to 2018 from the NIS. The projected volumes of THA and TKA were modeled using negative binomial regression models while incorporating log-transformed population data from the Centers for Disease Control and Prevention. Annual volume increased by 26% for THA and 11% for TKA (2008/2018: THA: 360,891/465,559; TKA:592,352/657,294). Based on 2008 to 2018 data, THA volume is projected to grow 120%, to 1,119,942 THAs by 2050. While, based on 2008 to 2017 data, THA volume is projected to grow 136%, to 1,219,852 THAs by 2050. Based on 2008 to 2018 data, TKA volume is projected to grow 4%, to 794,852 TKAs by 2050. While, based on 2008 to 2017 data, TKA volume is projected to grow 28%, to 1,037,474 TKAs by 2050. Projections based on 2008 to 2017 data estimated up to 240,000 (23%) more annual TKAs by 2050, compared with projections based on 2008 to 2018 data. The largest discrepancy among THA projections was an 8.2% difference (99,000 THAs) for 2050. After 2018 for TKA, and potentially 2020 for THA, projections based on the NIS will have to be interpreted with caution and may only be appropriate to estimate future inpatient volume. Level of evidence is prognostic level II.
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Affiliation(s)
- Pedro J Rullán
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Ignacio Pasqualini
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Siran Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Wael K Barsoum
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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12
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Mariner Gonzalez A, Reyes SG, Ho AA, Brown O, Franklin P, Suleiman LI. Underrepresentation of Non-White Participants in the American Academy of Orthopaedic Surgeons Guidelines for Surgical Management of Knee Osteoarthritis. J Arthroplasty 2024; 39:520-526. [PMID: 37572721 PMCID: PMC11210326 DOI: 10.1016/j.arth.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the racial and ethnic representation in studies included in the 2015 American Academy of Orthopaedic Surgeons Surgical Management of the Knee Evidence-Based Clinical Practice Guideline relative to their representation of the United States (US). METHODS The demographic characteristics reported in articles included in the 2015 American Academy of Orthopaedic Surgeons Surgical Management of the Knee Evidence-Based Clinical Practice Guideline were analyzed. The primary outcome of interest was the representation quotient, which is the ratio of the proportion of a racial/ethnic group in the guideline studies relative to their proportion in the US. There were 211 studies included, of which 15 (7%) reported race. There were 35 studies based in the US and 7 of the US-based studies reported race. RESULTS No US-based studies reported race and ethnicity separately, no studies reported American Indian/Alaska Native participants and no US-based studies reported Asian participants. The representation quotient of US-based studies was 0.66 for Black participants, 0.33 for Hispanic participants, and 1.30 for White participants, which indicates a relative over-representation of White participants compared to national proportions. CONCLUSION This study illustrated that the evidence base for the surgical management of knee osteoarthritis has been constructed from studies which fail to consider race and ethnicity. Of those US-based studies which do report race or ethnicity, study cohorts do not reflect the US population. These results illustrate a disparity in clinical orthopedic surgical evidence and highlight the need for improved research recruitment strategies.
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Affiliation(s)
- Alba Mariner Gonzalez
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samuel G Reyes
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alisha A Ho
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Oluwateniola Brown
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Patricia Franklin
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Thirukumaran CP, Fiscella KA, Rosenthal MB, Doshi JA, Schloemann DT, Ricciardi BF. Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements. J Am Geriatr Soc 2024; 72:102-112. [PMID: 37772461 PMCID: PMC10841259 DOI: 10.1111/jgs.18605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics – University of Rochester, NY
- Department of Public Health Sciences – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Kevin A. Fiscella
- Department of Public Health Sciences – University of Rochester, NY
- Department of Family Medicine – University of Rochester, NY
| | - Meredith B. Rosenthal
- Department of Health Policy and Management – Harvard T. H. Chan School of Public Health, MA
| | - Jalpa A. Doshi
- Division of General Internal Medicine – University of Pennsylvania Perelman School of Medicine, PA
| | - Derek T. Schloemann
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Benjamin F. Ricciardi
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
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Oddleifson DA, Xu X, Wiznia D, Gibson D, Spatz ES, Desai NR. Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries. J Am Acad Orthop Surg 2023; 31:e961-e973. [PMID: 37543752 DOI: 10.5435/jaaos-d-23-00183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/11/2023] [Indexed: 08/07/2023] Open
Abstract
INTRODUCTION This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality. METHODS This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included. For the market-level analysis, we assessed the association of social vulnerability with the presence of a high-quality hip and knee replacement center. For the hospital-level analysis, we assessed the association of disproportionate share hospital (DSH) percentage with each high-quality designation. Healthcare markets were approximated by hospital referral regions. All associations were assessed with fractional regressions using generalized linear models with binomial family and logit links. RESULTS We found that healthcare markets in the most vulnerable quartile were less likely to have a hip and knee replacement hospital that did better than the national average (odds ratio [OR] 0.22, P = 0.02) but not more or less likely to have a hospital certified as advanced by JC (OR 0.41, P = 0.16). We found that hip and knee replacement hospitals in the highest DSH quartile were less likely to be designated by the Centers for Medicare and Medicaid Services as better than the national average (OR 0.18, P = 0.001) but not more or less likely to be certified as advanced by JC (OR 1.40, P = 0.28). DISCUSSION Geographic distribution of high-quality hospitals may contribute to socioeconomic disparities in patients' access to and utilization of high-quality hip and knee replacement. Equal access to and utilization of hospitals with high-quality surgical processes does not necessarily indicate equitable access to and utilization of hospitals with high-quality outcomes. LEVEL OF EVIDENCE Level III.
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Rubery PT, Ramirez G, Kwak A, Thirukumaran C. Racial/ethnic and income-based differences in the use of surgery for cervical and lumbar disorders in New York State: a retrospective analysis. Spine J 2023:S1529-9430(23)03465-4. [PMID: 37890728 DOI: 10.1016/j.spinee.2023.10.012] [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: 03/30/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND CONTEXT The extent to which use of spine surgeries for patients with cervical and lumbar disorders varies by their race/ethnicity and income is currently unknown. PURPOSE To assess racial/ethnic and income-based differences in use of spine surgery in New York State (NYS) from 2016 to 2019. STUDY DESIGN Retrospective observational analysis using 2016 to 2019 New York Statewide Planning and Research Cooperative System (SPARCS) data, direct standardization, and multivariable mixed-effects linear regression models. METHODS A dataset of patients who underwent surgery for cervical and spinal disorders in NYS in the period 2016 to 2019 was used to determine county-level age- and sex-standardized annual cervical and lumbar surgery rates expressed as number of surgeries per 10,000 individuals. Further sub-analysis was performed with the key independent variables being the combination of individual-level race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic individuals) and income (low-/high-income residing in zip codes below/above state median income); and year. We estimated multivariable mixed-effects linear regression models which controlled county-level variables to determine the adjusted rates of spine surgeries for patients belonging to various race/ethnicity and income group combinations. RESULTS The study included 29,650 and 42,498 patients in the cervical and lumbar cohorts, respectively. In 2019, the county-level mean cervical and lumbar surgery rates were 3.88 and 5.19 surgeries per 10,000 individuals, respectively. There was a five-fold rate variation across NYS. In 2019, the adjusted cervical rates were 4.59 (White low-income), 4.96 (White high-income), 7.20 (Black low-income), 3.01 (Black high-income), 4.37 (Hispanic low-income), and 1.17 (Hispanic high-income). The adjusted lumbar rates were 5.49 (White low-income), 6.31 (White high-income), 9.43 (Black low-income), 2.47 (Black high-income), 4.22 (Hispanic low-income), and 2.02 (Hispanic high-income). The rates for low-income Black or Hispanic patients were significantly higher than their high-income counterparts. Low-income Black patients had the highest rates. Over the study period, the gap/difference increased significantly between high-income Hispanic and White individuals by 2.19 (95% confidence interval [CI]: -4.27, -0.10, p=.04) for cervical surgery; and between low-income Black and White individuals by 2.82 (2.82, 95% CI: 0.59, 5.06, p=.01) for lumbar surgery. CONCLUSION There are differences in the rates of spine surgery in New York State, among identifiable groups. Black individuals from poorer zip codes experience relatively higher spine surgery rates. Understanding the drivers of surgical rate variation is key to improving the equitable delivery of spine care. A better understanding of such rate variations could inform health policy.
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Affiliation(s)
- Paul T Rubery
- Department of Orthopaedics - University of Rochester, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA; Center for Musculoskeletal Research - University of Rochester, 601 Elmwood Ave., Rochester, NY 14642, USA.
| | - Gabriel Ramirez
- Department of Orthopaedics - University of Rochester, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA; Center for Musculoskeletal Research - University of Rochester, 601 Elmwood Ave., Rochester, NY 14642, USA
| | - Amelia Kwak
- University of Rochester, 500 Joseph C. Wilson Blvd., Rochester, NY 14627, USA
| | - Caroline Thirukumaran
- Department of Orthopaedics - University of Rochester, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA; Center for Musculoskeletal Research - University of Rochester, 601 Elmwood Ave., Rochester, NY 14642, USA; Department of Public Health Sciences - University of Rochester, 601 Elmwood Ave., Rochester, NY 14642, USA
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Steinbeck V, Langenberger B, Schöner L, Wittich L, Klauser W, Mayer M, Kuklinski D, Vogel J, Geissler A, Pross C, Busse R. Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2331301. [PMID: 37656459 PMCID: PMC10474554 DOI: 10.1001/jamanetworkopen.2023.31301] [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: 05/01/2023] [Accepted: 07/23/2023] [Indexed: 09/02/2023] Open
Abstract
Importance Although remote patient-reported outcome measure (PROM) monitoring has shown promising results in cancer care, there is a lack of research on PROM monitoring in orthopedics. Objective To determine whether PROM monitoring can improve health outcomes for patients with joint replacement compared with the standard of care. Design, Setting, and Participants A 2-group, patient-level randomized clinical trial (PROMoting Quality) across 9 German hospitals recruited patients aged 18 years or older with primary hip or knee replacement from October 1, 2019, to December 31, 2020, with follow-up until March 31, 2022. Interventions Intervention and control groups received the standard of care and PROMs at hospital admission, discharge, and 12 months after surgery. In addition, the intervention group received PROMs at 1, 3, and 6 months after surgery. Based on prespecified PROM score thresholds, at these times, an automated alert signaled critical recovery paths to hospital study nurses. On notification, study nurses contacted patients and referred them to their physicians if necessary. Main Outcomes and Measures The prespecified outcomes were the mean change in PROM scores (European Quality of Life 5-Dimension 5-Level version [EQ-5D-5L; range, -0.661 to 1.0, with higher values indicating higher levels of health-related quality of life (HRQOL)], European Quality of Life Visual Analogue Scale [EQ-VAS; range, 0-100, with higher values indicating higher levels of HRQOL], Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform [HOOS-PS; range, 0-100, with lower values indicating lower physical impairment] or Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform [KOOS-PS; range, 0-100, with lower values indicating lower physical impairment], Patient-Reported Outcomes Measurement Information System [PROMIS]-fatigue [range, 33.7-75.8, with lower values indicating lower levels of fatigue], and PROMIS-depression [range, 41-79.4, with lower values indicating lower levels of depression]) from baseline to 12 months after surgery. Analysis was on an intention-to-treat basis. Results The study included 3697 patients with hip replacement (mean [SD] age, 65.8 [10.6] years; 2065 women [55.9%]) and 3110 patients with knee replacement (mean [SD] age, 66.0 [9.2] years; 1669 women [53.7%]). Exploratory analyses showed significantly better health outcomes in the intervention group on all PROMs except the EQ-5D-5L among patients with hip replacement, with a 2.10-point increase on the EQ-VAS in the intervention group compared with the control group (HOOS-PS, -1.86 points; PROMIS-fatigue, -0.69 points; PROMIS-depression, -0.57 points). Patients in the intervention group with knee replacement had a 1.24-point increase on the EQ-VAS, as well as significantly better scores on the KOOS-PS (-0.99 points) and PROMIS-fatigue (-0.84 points) compared with the control group. Mixed-effect models showed a significant difference in improvement on the EQ-VAS (hip replacement: effect estimate [EE], 1.66 [95% CI, 0.58-2.74]; knee replacement: EE, 1.71 [95% CI, 0.53-2.90]) and PROMIS-fatigue (hip replacement: EE, -0.65 [95% CI, -1.12 to -0.18]; knee replacement: EE, -0.71 [95% CI, -1.23 to -0.20]). The PROMIS-depression score was significantly reduced in the hip replacement group (EE, -0.60 [95% CI, -1.01 to -0.18]). Conclusions and Relevance In this randomized clinical trial, the PROM-based monitoring intervention led to a small improvement in HRQOL and fatigue among patients with hip or knee replacement, as well as in depression among patients with hip replacement. Trial registration Deutsches Register Klinischer Studien ID: DRKS00019916.
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Affiliation(s)
- Viktoria Steinbeck
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Benedikt Langenberger
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Lukas Schöner
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Laura Wittich
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Wolfgang Klauser
- Department of Orthopedics, VAMED Ostseeklinik Damp, Damp, Germany
| | - Martin Mayer
- Department of Orthopedics, VAMED Ostseeklinik Damp, Damp, Germany
| | - David Kuklinski
- Chair of Healthcare Management, School of Medicine, University of St Gallen, St Gallen, Switzerland
| | - Justus Vogel
- Chair of Healthcare Management, School of Medicine, University of St Gallen, St Gallen, Switzerland
| | - Alexander Geissler
- Chair of Healthcare Management, School of Medicine, University of St Gallen, St Gallen, Switzerland
| | - Christoph Pross
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Healthcare Management, School of Economics and Management, Technical University Berlin, Berlin, Germany
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Boakye LAT, Parker EB, Chiodo CP, Bluman EM, Martin EA, Smith JT. The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions. J Bone Joint Surg Am 2023; 105:1062-1071. [PMID: 36996237 DOI: 10.2106/jbjs.22.01149] [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: 04/01/2023]
Abstract
BACKGROUND Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores. METHODS We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors. RESULTS For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores. CONCLUSIONS Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lorraine A T Boakye
- Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Emily B Parker
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher P Chiodo
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric M Bluman
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Martin
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy T Smith
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Dlott CC, Metcalfe T, Bahel A, Jain S, Donnelley CA, Kayani J, Wiznia DH. Characterizing the lack of diversity in musculoskeletal urgent care website content. BMC Health Serv Res 2023; 23:297. [PMID: 36978168 PMCID: PMC10053459 DOI: 10.1186/s12913-023-09270-5] [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: 12/05/2022] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Musculoskeletal urgent care centers (MUCCs) are becoming an alternative to emergency departments for non-emergent orthopedic injuries as they can provide direct access to orthopedic specialty care. However, they tend to be located in more affluent geographies and are less likely to accept Medicaid insurance than general urgent care centers. MUCCs utilize websites to drive patients to their centers, and the content may influence patients' consumer behaviors and perceptions of the quality and accessibility of the MUCCs. Given that some MUCCs target insured patient populations, we evaluated the racial, gender, and body type diversity of website content for MUCCs. METHODS Our group conducted an online search to create a list of MUCCs in the United States. For each MUCC, we analyzed the content featured prominently on the website (above the fold). For each website, we analyzed the race, gender, and body type of the featured model(s). MUCCs were classified according to their affiliation (i.e. academic versus private) and region (i.e. Northeast versus South). We performed chi-squared and univariate logistic regression to investigate trends in MUCC website content. RESULTS We found that 14% (32/235) of website graphics featured individuals from multiple racial groups, 57% (135/235) of graphics featured women, and 2% (5/235) of graphics featured overweight or obese individuals. Multiracial presence in website graphics was associated with the presence of women on the websites and Medicaid acceptance. CONCLUSION MUCC website content has the potential to impact patients' perceptions of medical providers and the medical care they receive. Most MUCC websites lack diversity based on race and body type. The lack of diversity in website content at MUCCs may introduce further disparities in access to orthopedic care.
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Affiliation(s)
- Chloe C Dlott
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA.
| | - Tanner Metcalfe
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Anchal Bahel
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Sanjana Jain
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Claire A Donnelley
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Jehanzeb Kayani
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
| | - Daniel H Wiznia
- Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT, 06519, USA
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Comorbidity, Racial, and Socioeconomic Disparities in Total Knee and Hip Arthroplasty at High Versus Low-Volume Centers. J Am Acad Orthop Surg 2023; 31:e264-e270. [PMID: 36729540 DOI: 10.5435/jaaos-d-22-00665] [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: 07/13/2022] [Accepted: 10/22/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The purpose of this study was to compare the epidemiologic and demographic profiles and inpatient postoperative complication and economic outcomes of patients undergoing total joint arthroplasty of the hip and knee (TJA) at high-volume centers (HVCs) versus low-volume centers (LVCs) using a large national registry. METHODS This retrospective cohort study used data from the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years or older receiving a primary total hip arthroplasty or total knee arthroplasty were included. Patients were stratified into those undergoing their procedure at HVCs versus LVCs. Epidemiologic, demographic, and inpatient postoperative complications and economic outcomes were comparatively analyzed between groups. RESULTS A total of 7,694,331 TJAs were conducted at HVCs while 1,044,358 were conducted at LVCs. Patients at LVCs were more likely to be female, be Hispanic, be non-Hispanic Black, and use Medicare and Medicaid than patients at HVCs. Of the 29 Elixhauser comorbidities examined, 14 were markedly higher at LVCs while 11 were markedly higher at HVCs. Patients who underwent TJA at LVCs were more likely to develop cardiac, respiratory, gastrointestinal, genitourinary, hematoma/seroma, wound dehiscence, and postoperative infection complications and were more likely to die during hospitalization. Patients at HVCs were more likely to develop postoperative anemia. Length of stay and total charges were higher at LVCs compared with HVCs. DISCUSSION There are notable differences in the demographics, epidemiologic characteristics, and inpatient outcomes of patients undergoing TJA at HVCs versus LVCs. Attention should be directed to identifying and applying the specific resources, processes, and practices that improve outcomes at HVCs while referral practices and centralization efforts should be mindful to not worsen already existing disparities.
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Karimi A, Burkhart RJ, Hecht CJ, Acuña AJ, Kamath AF. Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review. Clin Orthop Relat Res 2023; 481:239-250. [PMID: 36103392 PMCID: PMC9831197 DOI: 10.1097/corr.0000000000002394] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity. QUESTIONS/PURPOSES We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)? METHODS A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively. RESULTS Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles. CONCLUSION These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Amir Karimi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J. Burkhart
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christian J. Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J. Acuña
- 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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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: 24] [Impact Index Per Article: 24.0] [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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22
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Ackerman SJ, Vigdorchik JM, Siljander BR, Gililland JM, Sculco PK, Polly DW. Projected Savings Associated with Lowering the Risk of Total Hip Arthroplasty Revision Due to Dislocation in Patients with Spinopelvic Pathology. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:321-330. [PMID: 37143936 PMCID: PMC10153402 DOI: 10.2147/ceor.s410453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/15/2023] [Indexed: 05/06/2023] Open
Abstract
Purpose In the United States (US), total hip arthroplasty (THA) is the most common hospital inpatient operation among Medicare beneficiaries and is ranked fourth when considering all payers. Spinopelvic pathology (SPP) is associated with an increased risk of THA revision (rTHA) due to dislocation. Several strategies have been proposed to mitigate the risk of instability in this population, including use of dual-mobility implants, anterior-based surgical approaches, and technology-assistance (digital 2D/3D pre-surgical planning, computer navigation, and robotic assistance). For primary THA (pTHA) patients with SPP who subsequently undergo rTHA due to dislocation, we aimed to estimate (1) target population size; (2) economic burden; and (3) 10-year projected savings to the US payer of lowering the risk of rTHA due to dislocation among pTHA patients with SPP. Methods A budget impact analysis from the US payer perspective was undertaken using published literature; American Academy of Orthopaedic Surgeons American Joint Replacement Registry 2021 Annual Report; Centers for Medicare & Medicaid Services MEDPAR 2019; and National (Nationwide) Inpatient Sample (NIS) 2019. Expenditures were inflation-adjusted to 2021 US dollars using the Medical Care component of the Consumer Price Index. Sensitivity analyses were performed. Results The target population size in 2021 was estimated at 5040 (range, 4830-6309) for Medicare (fee-for-service plus Medicare Advantage) and 8003 (range, 7669-10,018) for all-payer. Annual rTHA episode-of-care (through 90 days) expenditures for Medicare and all-payer were $185 million and $314 million, respectively. Using a 4.14% compound annual growth rate from NIS, the estimated number of applicable rTHA procedures that will be performed from 2022-2031 was 63,419 Medicare and 100,697 all-payer. With each 10% reduction in relative risk of rTHA due to dislocation, Medicare and all-payer could save $233 million and $395 million, respectively, over a 10-year period. Conclusion Among pTHA patients with spinopelvic pathology, a modest reduction in the risk of rTHA due to dislocation could achieve substantial cumulative savings to payers while improving healthcare quality.
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Affiliation(s)
- Stacey J Ackerman
- Department of Biomedical Engineering, Johns Hopkins University, San Diego, CA, USA
- Correspondence: Stacey J Ackerman, Email
| | | | - Breana R Siljander
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jeremy M Gililland
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
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23
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Holbert SE, Brennan JC, Johnson AH, MacDonald JH, Turcotte JJ, King PJ. Racial Disparities in Outcomes of Total Joint Arthroplasty at a Single Institution: Have We Made Progress? Arthroplast Today 2022; 19:101059. [PMID: 36568850 PMCID: PMC9772798 DOI: 10.1016/j.artd.2022.10.009] [Citation(s) in RCA: 3] [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: 09/21/2022] [Accepted: 10/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Health disparities disproportionately affect minority groups across the United States with respect to care access, quality, and outcomes. The aim of this study is to examine existing disparities between white and African American (AA) patients regarding postoperative outcomes following total joint arthroplasty and provide insight into disparity trends over a 9-year period. Methods A retrospective review of 16,779 total joint arthroplasty patients at a single institution between January 2013 and December 2021 was performed. Patients were grouped by race as AA or white. Outcomes of interest included length of stay (LOS), home discharge, 30-day emergency department return, and 30-day readmission. Univariate statistics and multivariate regressions were utilized to analyze results. Results Significant improvements in LOS and rates of home discharge occurred for both white and AA patients at our institution over a 9-year period, while rates of 30-day emergency department returns and readmissions demonstrated a downward but non-statistically significant trend. Despite these trends, AA patients continued to experience longer lengths of stay, less likelihood of 0- or 1-day LOS, and higher risk of nonhome discharge for most years examined. However, after controlling for demographic and comorbidity differences, the differences between groups narrowed over time resulting in no significant differences in the aforementioned 3 measures by 2021. Conclusions Although racial disparities in outcomes are still apparent, over time, the differences in resource utilization between AA and white patients have narrowed. Initiatives aimed at creating healthier communities with increased access to care and the ultimate goal of equitable care must continue to be pursued.
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Affiliation(s)
| | | | | | | | - Justin J. Turcotte
- Corresponding author. Luminis Health Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, USA. Tel.: +1 410 271 2674.
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Wu VS, Acuña AJ, Kim AG, Burkhart RJ, Kamath AF. Impact of social disadvantage among total knee arthroplasty places of service on procedural volume: a nationwide Medicare analysis. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04708-7. [PMID: 36454304 DOI: 10.1007/s00402-022-04708-7] [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: 09/16/2022] [Accepted: 11/19/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION As recent analyses have indicated that low-volume hospitals experience higher rates of complications following total knee arthroplasty (TKA), it remains important to evaluate how area deprivation index (ADI) of hospitals impacts the quantity of TKA performed. Our analysis sought to evaluate how the ADI of orthopedic surgeon's place of service influences TKA utilization. MATERIALS AND METHODS The Medicare Provider Utilization and Payment Data Public Use File (MPUP-PUF) was queried to identify claims between 2013 and 2019 associated with Healthcare Common Procedure Coding System (HCPCS) code 27447 (TKA). The MPUP-PUF file was linked with publicly available ADI information as well as information regarding each provider's practice location. The Mann-Kendall trend test was used to analyze significant differences in TKA volume between ADI quintiles and differences in TKA volume overall between the years 2013 and 2019. An adjusted multivariable linear regression analysis was conducted to evaluate how ADI, and practice-specific characteristics, influenced TKA utilization volume. RESULTS When isolating by ADI quintiles, no significant changes in TKA volume were demonstrated for Quintile 4 (Kendall's τ = 0.524; p = 0.13) and Quintile 5 (Kendall's τ = 0.524; p = 0.13) between 2013 and 2019. However, a significant increase in TKA volume over the study period was observed in Quintile 1 (Kendall's τ = 0.714 p = 0.034), Quintile 2 (Kendall's τ = 0.714 p = 0.034), and Quintile 3 (Kendall's τ = 0.905 p = 0.007). The adjusted multivariable linear regression model demonstrated that each increase in ADI quintile was associated with significantly lower TKA utilization (β-estimate - 1.16; 95% CI - 2.04 to - 0.29; p = 0.009). CONCLUSIONS Our findings suggest that resource deprivation contributes to disparities in TKA utilization. With the ongoing recognition of how social and neighborhood-level deprivation may influence access to end-stage osteoarthritis care and related perioperative outcomes, the present study serves to encourage continued efforts at ensuring equity in orthopedic care.
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Affiliation(s)
- Victoria S Wu
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Andrew G Kim
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Robert J Burkhart
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, 44195, USA.
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Hwang A, Zhang L, Ramirez G, Maloney M, Voloshin I, Thirukumaran C. Black Race, Hispanic Ethnicity, and Medicaid Insurance Are Associated With Lower Rates of Rotator Cuff Repair in New York State. Arthroscopy 2022; 38:3001-3010.e2. [PMID: 35817374 DOI: 10.1016/j.arthro.2022.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair. METHODS A retrospective review of the Statewide Planning and Research Cooperative System Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months of follow-up. Bivariate analysis using χ2 tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair. RESULTS A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (adjusted odds ratio [aOR] 0.78; 95% confidence interval [CI] 0.69-0.87; P < .001), Hispanic/Latino ethnicity (aOR 0.91; 95% CI 0.85-0.97); P = .004), and Medicaid (aOR 0.75; 95% CI 0.70-0.80; P < .001), or other government insurance (aOR 0.82; 95% CI 0.78-0.86; P < .001) were independently associated with lower rates of rotator cuff repair. Male sex (aOR 1.18; 95% CI 1.14-1.22; P < .001), Asian race (aOR 1.27; 95% CI 1.00-1.62; P = .048), workers' compensation insurance (aOR 1.12; 95% CI 1.07-1.18; P < .001), and greater home ZIP code income quartile (aOR 1.19; 95% CI 1.09-1.30; P < .001) were independently associated with greater rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology. CONCLUSIONS In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017 to 2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home ZIP code income quartile. CLINICAL RELEVANCE This study reports disparities in the use of rotator cuff repair for individuals with rotator cuff pathology.
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Affiliation(s)
- Alan Hwang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A..
| | - Linda Zhang
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Gabriel Ramirez
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Michael Maloney
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Ilya Voloshin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Caroline Thirukumaran
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, U.S.A
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Association Between Race/Ethnicity and Total Joint Arthroplasty Utilization in a Universally Insured Population. J Am Acad Orthop Surg 2022; 30:e1348-e1357. [PMID: 36044283 DOI: 10.5435/jaaos-d-22-00146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Previous studies have documented racial and ethnic disparities in total joint arthroplasty (TJA) utilization in the United States. A potential mediator of healthcare disparities is unequal access to care, and studies have suggested that disparities may be ameliorated in systems of universal access. The purpose of this study was to assess whether racial/ethnic disparities in TJA utilization persist in a universally insured population of patients enrolled in a managed healthcare system. METHODS This retrospective cohort study used data from a US integrated healthcare system (2015 to 2019). Patients aged 50 years and older with a diagnosis of hip or knee osteoarthritis were included. The outcome of interest was utilization of primary total hip arthroplasty and/or total knee arthroplasty, and the exposure of interest was race/ethnicity. Incidence rate ratios (IRRs) were modeled using multivariable Poisson regression controlling for confounders. RESULTS There were 99,548 patients in the hip analysis and 290,324 in the knee analysis. Overall, 10.2% of the patients were Black, 20.5% were Hispanic, 9.6% were Asian, and 59.7% were White. In the multivariable analysis, utilization of primary total hip arthroplasty was significantly lower for all minority groups including Black (IRR, 0.55, 95% confidence interval [CI], 0.52-0.57, P < 0.0001), Hispanic (IRR, 0.63, 95% CI, 0.60-0.66, P < 0.0001), and Asian (IRR, 0.64, 95% CI, 0.61-0.68, P < 0.0001). Similarly, utilization of primary total knee arthroplasty was significantly lower for all minority groups including Black (IRR, 0.52, 95% CI, 0.49-0.54, P < 0.0001), Hispanic (IRR, 0.72, 95% CI, 0.70-0.75, P < 0.0001), and Asian (IRR, 0.60, 95% CI, 0.57-0.63, P < 0.0001) (all in comparison with White as reference). CONCLUSIONS In this study of TJA utilization in a universally insured population of patients enrolled in a managed healthcare system, disparities on the basis of race and ethnicity persisted. Additional research is required to determine the reasons for this finding and to identify interventions which could ameliorate these disparities.
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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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Kamath CC, O’Byrne TJ, Lewallen DG, Berry DJ, Maradit Kremers H. Neighborhood-Level Socioeconomic Deprivation, Rurality, and Long-Term Outcomes of Patients Undergoing Total Joint Arthroplasty: Analysis from a Large, Tertiary Care Hospital. Mayo Clin Proc Innov Qual Outcomes 2022; 6:337-346. [PMID: 35814186 PMCID: PMC9256822 DOI: 10.1016/j.mayocpiqo.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the impact of neighborhood-level socioeconomic status factors (area deprivation index [ADI] and rural classification) and their interaction with individual-level socioeconomic status (education-level) on long-term outcomes following total joint arthroplasty (TJA) surgery. Patients and Methods This was a cohort study of 46,828 TJA surgeries performed on patients at a tertiary care hospital between January 1, 2000 and December 31, 2019. Cox proportional hazards models were used to examine the association between ADI and rurality and their interaction with individual-level education on the risk of periprosthetic joint infections, revision surgery, and mortality. Results At the time of surgery, 2589 (6%) patients lived in the most deprived neighborhoods (ADI quintile >80%) and 10,728 (23%) lived in small isolated rural towns. Patients from the most deprived neighborhoods were more likely to experience revision surgery (hazard ratio, [HR], 1.39; 95% CI, 1.10-1.76) and mortality (HR, 1.24; 95% CI, 1.09-1.42). Patients from small rural towns were also more likely to undergo revision surgery (HR, 1.14; 95% CI, 1.01-1.28). The mortality risk was 13%, 18%, and 24% higher for patients in the 3 highest ADI quintiles than those from the lowest quintile. Education gradient was more notable in the least deprived neighborhoods than in the most deprived neighborhoods. Conclusion Neighborhood disadvantage and rurality are negatively associated with the risk of revision surgery and both independently and in interaction with individual-level education with the risk of mortality. There is a need for population-level health interventions to mitigate area-based socioeconomic disadvantages in TJA.
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Affiliation(s)
- Celia C. Kamath
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Thomas J. O’Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Hilal Maradit Kremers
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
- Correspondence: Address to Hilal Maradit Kremers, MD, Department of Quantitative Health Science, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905.
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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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Carender CN, DeMik DE, Elkins JM, Brown TS, Bedard NA. Are Body Mass Index Cutoffs Creating Racial, Ethnic, and Gender Disparities in Eligibility for Primary Total Hip and Knee Arthroplasty? J Arthroplasty 2022; 37:1009-1016. [PMID: 35182664 DOI: 10.1016/j.arth.2022.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/27/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Unabated increases in the prevalence of obesity among American adults have disproportionately affected women, Black persons, and Hispanic persons. The purpose of this study was to evaluate for disparity in rates of patient eligibility for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) based on race and ethnicity and gender by applying commonly used body mass index (BMI) eligibility criteria to two large national databases. METHODS We retrospectively reviewed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2015-2019 for primary THA and TKA and the National Health and Nutrition Examination Survey (NHANES) from 2011-2018. Designations of race and ethnicity were standardized between cohorts. BMI cutoffs of <50 kg/m2, <45 kg/m2, <40 kg/m2, and <35 kg/m2 were then applied. Rates of eligibility for surgery were examined for each respective BMI cutoff and stratified by age, race and ethnicity, and gender. RESULTS 143,973 NSQIP THA patients, 242,518 NSQIP TKA patients, and 13,255 NHANES participants were analyzed. Female patients were more likely to be ineligible for surgery across all cohorts for all modeled BMI cutoffs (P < .001 for all). Black patients had relatively lower rates of eligibility across all cohorts for all modeled BMI cutoffs (P < .0001 for all). Hispanic patients had disproportionately lower rates of eligibility only at a BMI cutoff of <35 kg/m2. CONCLUSION Using BMI cutoffs alone to determine the eligibility for primary THA and TKA may disproportionally exclude women, Black persons, and Hispanic persons. These data raise concerns regarding further disparity and restriction of arthroplasty care to vulnerable populations that are already marginalized. LEVEL OF EVIDENCE Retrospective Cohort Study, Level III.
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Affiliation(s)
- Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jacob M Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
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Carender CN, Glass NA, DeMik DE, Elkins JM, Brown TS, Bedard NA. Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get? J Arthroplasty 2022; 37:874-879. [PMID: 35124192 DOI: 10.1016/j.arth.2022.01.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029. METHODS Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese. CONCLUSION By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jacob M Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
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32
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Owusu-Akyaw K. The Forward Movement: Amplifying Black Voices on Race and Orthopaedics-Can Orthopaedics Move Beyond Historic Biases in Black Patient Pain Perception? Clin Orthop Relat Res 2022; 480:870-871. [PMID: 35348492 PMCID: PMC9007203 DOI: 10.1097/corr.0000000000002198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
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Golla V, Allen Lapointe NM, Silberberg M, Wang V, Lentz TA, Kaye DR, Sorenson C, Saunders R, Kaufman BG. Improving health equity for older people with serious illness through value based payment reform. J Am Geriatr Soc 2022; 70:2180-2185. [PMID: 35474173 DOI: 10.1111/jgs.17815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Vishnukamal Golla
- National Clinician Scholars Program, Duke University, Durham, North Carolina, USA.,Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA
| | - Nancy M Allen Lapointe
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mina Silberberg
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Virginia Wang
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Trevor A Lentz
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Duke Cancer Institute, Durham, North Carolina, USA
| | - Corinna Sorenson
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA.,Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Robert Saunders
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Health Services Research and Development, Durham VA Healthcare System, Durham, North Carolina, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Patients From Medically Underserved Areas Are at Increased Risk for Nonhome Discharge and Emergency Department Return After Total Joint Arthroplasty. J Arthroplasty 2022; 37:609-615. [PMID: 34990757 DOI: 10.1016/j.arth.2021.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/15/2021] [Accepted: 12/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Maryland Health Enterprise Zones (MHEZs) were introduced in 2012 and encompass underserved areas and those with reduced access to healthcare providers. Across the United States many underserved and minority populations experience poorer total joint arthroplasty (TJA) outcomes seemingly because they reside in underserved areas. The purpose of this study is to identify and quantify the relationship between living in an MHEZ and TJA outcomes. METHODS Retrospective review of 11,451 patients undergoing primary TJA at a single institution from July 1, 2014 to June 30, 2020 was conducted. Patients were classified based on whether they resided in an MHEZ. Statistical analyses were used to compare outcomes for TJA patients who live in MHEZ and those who do not. RESULTS Of the 11,451 patients, 1057 patients lived in MHEZ and 10,394 patients did not. After risk adjustment, patients who live in an MHEZ were more likely to return to the emergency department within 90 days postoperatively and were less likely to be discharged home than those patients who do not live in an MHEZ. CONCLUSION Total joint arthroplasty patients residing in MHEZ appear to present with poorer overall health as measured by increased American Society of Anesthesiologists and Hierarchical Condition Categories scores, and they are less likely to be discharged home and more likely to return to the emergency department within 90 days. Several factors associated with these findings such as socioeconomic factors, household composition, housing type, disability, and transportation may be modifiable and should be targets of future population health initiatives.
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Ko H, Martin BI, Nelson RE, Pelt CE. Patient selection in the Comprehensive Care for Joint Replacement model. Health Serv Res 2022; 57:72-90. [PMID: 34612519 PMCID: PMC8763283 DOI: 10.1111/1475-6773.13880] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/17/2021] [Accepted: 09/10/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To understand whether the Comprehensive Care for Joint Replacement (CJR) program induces participating hospitals to (1) preferentially select lower risk patients, (2) reduce 90-day episode-of-care costs, (3) improve quality of care, and (4) achieve greater cost reduction during its second year, when downside financial risk was applied. DATA SOURCES We identified beneficiaries of age 65 years or older undergoing hip or knee joint replacement in the 100% sample of Medicare fee-for-service inpatient (Part A) claims from January 1, 2013 to August 31, 2017. Cases were linked to subsequent outpatient, Part B, home health agency, and skilled nursing facility claims, as well as publicly available participation status for CJR. STUDY DESIGN We estimated the effect of CJR for hospitals in the 67 metropolitan statistical areas (MSA) selected to participate in CJR (785 hospitals), compared to those in 104 non-CJR MSAs (962 hospitals; maintaining fee-for-service). A difference-in-differences approach was used to detect patient selection, as well as to compare 90-day episode-of-care costs and quality of care between CJR and non-CJR hospitals over the first two performance years. DATA COLLECTION We excluded 172 hospitals from our analysis due to their preexisting BPCI participation. We focused on elective admissions in the main analysis. PRINCIPAL FINDINGS While reductions in 90-day episode-of-care costs were greater among CJR hospitals (-$902, 95% CI: -$1305, -$499), largely driven by a 16.8% (p < 0.01) decline in 90-day spending in skilled nursing facilities, CJR hospitals significantly reduced the 90-day readmission rate (-3.9%; p < 0.05) and preferentially avoided patients aged 85 years or older (-5.9%; p < 0.01) and Black (-7.0%; p < 0.01). Cost reduction was greater in 2017 than in 2016, corresponding to the start of downside risk. CONCLUSIONS Participation in CJR was associated with a modest cost reduction and a reduction in 90-day readmission rates; however, we also observed evidence of preferential avoidance of older patients perceived as being higher risk among CJR hospitals.
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Affiliation(s)
- Hyunkyu Ko
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
| | - Brook I. Martin
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
| | - Richard E. Nelson
- Division of EpidemiologyUniversity of UtahSalt Lake CityUtahUSA,Utah Department of Veterans AffairsSalt Lake CityUtahUSA
| | - Christopher E. Pelt
- Department of OrthopaedicsOrthopaedic Center, University of UtahSalt Lake CityUtahUSA
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36
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Jolley S, Nordon‐Craft A, Wilson MP, Ridgeway K, Rauzi MR, Capin J, Heery LM, Stevens‐Lapsley J, Erlandson KM. Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19. J Hosp Med 2022; 17:88-95. [PMID: 35446466 PMCID: PMC9088325 DOI: 10.1002/jhm.12785] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/05/2022] [Accepted: 01/16/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments. OBJECTIVE To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. DESIGN, SETTING AND PARTICIPANTS Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. MEASUREMENTS Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. RESULTS Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral. CONCLUSIONS AND RELEVANCE In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.
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Affiliation(s)
- Sarah Jolley
- Division of Pulmonary and Critical Care MedicineAuroraColardoUSA
| | - Amy Nordon‐Craft
- Physical Therapy ProgramDepartment of Physical Medicine and RehabilitationAuroraColoradoUSA
| | - Melissa P. Wilson
- Division of Bioinformatics and Personalized MedicineAuroraColoradoUSA
| | - Kyle Ridgeway
- Physical Therapy ProgramDepartment of Physical Medicine and RehabilitationAuroraColoradoUSA
- Inpatient Rehabilitation Therapy DepartmentUniversity of Colorado HospitalAuroraColoradoUSA
| | - Michelle R. Rauzi
- Physical Therapy ProgramDepartment of Physical Medicine and RehabilitationAuroraColoradoUSA
| | - Jacob Capin
- Physical Therapy ProgramDepartment of Physical Medicine and RehabilitationAuroraColoradoUSA
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC)AuroraColoradoUSA
| | | | - Jennifer Stevens‐Lapsley
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC)AuroraColoradoUSA
- Division of Infectious DiseasesUniversity of ColoradoAuroraColoradoUSA
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37
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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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38
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Fullwood D, Gomez RN, Huo Z, Cardoso JS, Bartley EJ, Booker SQ, Powell-Roach KL, Johnson AJ, Sibille KT, Addison AS, Goodin BR, Staud R, Redden DT, Fillingim RB, Terry EL. A Mediation Appraisal of Catastrophizing, Pain-Related Outcomes, and Race in Adults With Knee Osteoarthritis. THE JOURNAL OF PAIN 2021; 22:1452-1466. [PMID: 34033964 PMCID: PMC8915407 DOI: 10.1016/j.jpain.2021.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 12/19/2022]
Abstract
The current cross-sectional study investigates whether pain catastrophizing mediates the relationship between ethnicity/race and pain, disability and physical function in individuals with knee osteoarthritis. Furthermore, this study examined mediation at 2-year follow-up. Participants included 187 community-dwelling adults with unilateral or bilateral knee pain who screened positive for knee osteoarthritis. Participants completed several self-reported pain-related measures and pain catastrophizing subscale at baseline and 2-year follow-up. Non-Hispanic Black (NHB) adults reported greater pain, disability, and poorer functional performance compared to their non-Hispanic White (NHW) counterparts (Ps < .05). NHB adults also reported greater catastrophizing compared to NHW adults. Mediation analyses revealed that catastrophizing mediated the relationship between ethnicity/race and pain outcome measures. Specifically, NHB individuals reported significantly greater pain and disability, and exhibited lower levels of physical function, compared to NHW individuals, and these differences were mediated by higher levels of catastrophizing among NHB persons. Catastrophizing was a significant predictor of pain and disability 2-years later in both ethnic/race groups. These results suggest that pain catastrophizing is an important variable to consider in efforts to reduce ethnic/race group disparities in chronic pain. The findings are discussed in light of structural/systemic factors that may contribute to greater self-reports of pain catastrophizing among NHB individuals. PERSPECTIVE: The current study examines whether pain catastrophizing mediates the relationship between ethnicity/race and OA-related pain, disability, and functional impairment at baseline and during a 2-year follow-up period in non-Hispanic Black and non-Hispanic White adults with knee pain. These results point to the need for interventions that target pain catastrophizing.
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Affiliation(s)
- Dottington Fullwood
- University of Florida, Department of Aging and Geriatric Research, Gainesville, Florida
| | - Rebecca N Gomez
- University of Florida, College of Nursing, Gainesville, Florida
| | - Zhiguang Huo
- University of Florida, Department of Biostatistics, Gainesville, Florida
| | - Josue S Cardoso
- Pain Research and Intervention Center of Excellence (PRICE), University of Florida, Gainesville, Florida
| | - Emily J Bartley
- University of Alabama at Birmingham, Department of Psychology, Birmingham, Alabama
| | - Staja Q Booker
- University of Florida, College of Nursing, Gainesville, Florida
| | | | - Alisa J Johnson
- University of Florida, Department of Aging and Geriatric Research, Gainesville, Florida
| | - Kimberly T Sibille
- University of Florida, Department of Aging and Geriatric Research, Gainesville, Florida
| | - Adriana S Addison
- University of Florida, Community Dentistry and Behavioral Science, Gainesville, Florida
| | - Burel R Goodin
- University of Florida, Community Dentistry and Behavioral Science, Gainesville, Florida
| | - Roland Staud
- University of Florida, Department of Medicine, Gainesville, Florida
| | - David T Redden
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, Alabama
| | - Roger B Fillingim
- Pain Research and Intervention Center of Excellence (PRICE), University of Florida, Gainesville, Florida; University of Alabama at Birmingham, Department of Psychology, Birmingham, Alabama
| | - Ellen L Terry
- University of Florida, College of Nursing, Gainesville, Florida; University of Alabama at Birmingham, Department of Psychology, Birmingham, Alabama
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Ryan-Ndegwa S, Zamani R, Akrami M. Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review. Int J Equity Health 2021; 20:224. [PMID: 34641862 PMCID: PMC8506083 DOI: 10.1186/s12939-021-01561-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/24/2021] [Indexed: 11/20/2022] Open
Abstract
Persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the UK. Consequently, a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery. Database searches were performed using MEDLINE, PubMed and Web of Science. Studies with a focus on surgical need, access, provision and outcome were of interest. Inequalities were explored in the context of sociodemographic characteristics, socioeconomic status (SES), geographical location and hospital-related variables. Only studies in the context of the UK were included. Screening of search and extraction of data were performed and 482 articles were identified in the database search, of which 16 were eligible. Eligible studies consisted of eight cross-sectional studies, seven ecological studies and one longitudinal study. Although socioeconomic inequality has somewhat decreased, lower SES patients and ethnic minority patients demonstrate increased surgical needs, reduced access and poor outcomes. Lower SES and Black minority patients were younger and had more comorbidities. Surgical need increased with age. Women had greater surgical need and provision than men. Geographical inequality had reduced in Scotland, but a north-south divide persists in England. Rural areas received greater provision relative to need, despite increased travel for care. In all, access inequalities remain widespread and policy change driven by research is needed.
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Affiliation(s)
| | - Reza Zamani
- Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Mohammad Akrami
- Department of Engineering, College of Engineering, Mathematics, and Physical Sciences, University of Exeter, Exeter, UK.
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40
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Thirukumaran CP, Rosenthal MB. The Triple Aim for Payment Reform in Joint Replacement Surgery: Quality, Spending, and Disparity Reduction. JAMA 2021; 326:2782537. [PMID: 34297035 DOI: 10.1001/jama.2021.12070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Caroline P Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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41
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Thirukumaran CP, Kim Y, Cai X, Ricciardi BF, Li Y, Fiscella KA, Mesfin A, Glance LG. Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement. JAMA Netw Open 2021; 4:e2111858. [PMID: 34047790 PMCID: PMC8164097 DOI: 10.1001/jamanetworkopen.2021.11858] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/05/2021] [Indexed: 12/19/2022] Open
Abstract
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Cohort Studies
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/standards
- Elective Surgical Procedures/statistics & numerical data
- Eligibility Determination/standards
- Eligibility Determination/statistics & numerical data
- Female
- Healthcare Disparities/economics
- Healthcare Disparities/standards
- Healthcare Disparities/statistics & numerical data
- Humans
- Male
- Medicare/economics
- Medicare/standards
- Medicare/statistics & numerical data
- Race Factors
- Reimbursement Mechanisms
- Socioeconomic Factors
- United States
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Family Medicine, University of Rochester, Rochester, New York
- Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Addisu Mesfin
- Department of Orthopaedics, University of Rochester, Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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42
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SooHoo NF. Medicaid Expansion and Pent-up Demand for Total Joint Replacement: Commentary on an article by Christopher J. Dy, MD, MPH, FACS, et al.: "Increased Utilization of Total Joint Arthroplasty After Medicaid Expansion". J Bone Joint Surg Am 2021; 103:e24. [PMID: 33710006 DOI: 10.2106/jbjs.20.02103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nelson F SooHoo
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
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