Racial Differences in Care and Outcomes After Total Hip and Knee Arthroplasties: Did the Comprehensive Care for Joint Replacement Program Make a Difference?

The Role of Social Determinants of Health in the Delivery of Value-Based Care in Total Joint Arthroplasty

Health care delivery systems throughout the United States have transitioned to a value-based care model, shifting away from a fee-for-service model to instead emphasize patient health outcomes and the quality of medical care. Social determinants of health (SDOH) have been shown to have a large impact on patient health outcomes and thus, must play an integral role in the implementation of a value-based model. This is of particular interest in the field of lower extremity joint arthroplasty, where demand is rising in conjunction with expanded access to care. This article intends to address the following: (1) provide background on SDOH in the setting of value-based arthroplasty care; (2) explore the impact of SDOH on patient outcomes and costs following total joint arthroplasty; and (3) provide strategies for recognizing and addressing SDOH in practice.

Outcomes by Race and Ethnicity Following a Medicare Bundled Payment Program for Joint Replacement

Importance

The Comprehensive Care for Joint Replacement (CJR) model, a traditional Medicare bundled payment program for lower-extremity joint replacement, is associated with care for patients outside traditional Medicare. Whether CJR model outcomes have differed by patient race or ethnicity outside of traditional Medicare is unclear.

Objective

To evaluate outcomes associated with the CJR model among Hispanic patients not enrolled in traditional Medicare.

Design, Setting, and Participants

This cohort study used hospitalization data from California's Patient Discharge Dataset for all patients who underwent lower-extremity joint replacement in California between January 1, 2014, and December 31, 2017. In California, 3 metropolitan statistical areas (MSAs) were randomly selected to participate in CJR in April 2016. Hospitals not participating in other Medicare Alternative Payment Models were included in the treated group if they were in these 3 MSAs and in the control group if they were in the remaining 23 MSAs. The data analysis was performed between October 1 and December 31, 2023.

Exposure

Comprehensive Care for Joint Replacement program implementation.

Main Outcomes and Measures

The main outcomes were hospital length of stay and home discharge rates by race and ethnicity. Home discharge status included self-care, the use of home health services, and hospice care at home. Event study, difference-in-differences, and triple differences models were used to estimate differential changes in health care service use by race and ethnicity for patients in the treated MSAs compared with the control MSAs before vs after CJR implementation.

Results

Of 309 834 hospitalizations (patient mean [SD] age, 68.3 [11.3] years; 60.6% women; 14.8% Hispanic; 72.4% non-Hispanic White), 48.0% were in treated MSAs and 52.0% in control MSAs. The CJR program was associated with an increase in home discharge rates for patients without traditional Medicare coverage; however, the increase differed by patient race and ethnicity. The increase was 0.05 (95% CI, 0.02-0.08) percentage points higher for Hispanic patients with Medicare Advantage and 0.03 (95% CI, 0.01-0.04) percentage points higher for Hispanic patients without Medicare compared with their non-Hispanic White counterparts.

Conclusions and Relevance

This cohort study shows that CJR program outcomes differed by race and ethnicity for patients covered outside traditional Medicare, with home discharge rates increasing more for Hispanic compared with non-Hispanic White patients. These findings suggest the importance of considering differential outcomes of Medicare payment policies for racial and ethnic minority patient populations beyond the initially targeted groups.

Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study

BACKGROUND

Disparities in orthopedic trauma care have been reported for racial-ethnic minority and socially disadvantaged patients. We examined differences in perioperative metrics by patient race and ethnicity and insurance after pelvic fracture in a national sample in the United States.

MATERIALS AND METHODS

The 2016-2019 National Inpatient Sample was queried for White, Black, and Hispanic patients 18 to 64 years old with private, Medicaid, or self-pay insurance who underwent non-elective pelvic fracture surgery. Associations between combined race and ethnicity and insurance subgroups and perioperative metrics (time to surgery, length of stay, inhospital complications, institutional discharge) were assessed using multivariable generalized linear and logistic regression models. Adjusted percent differences or odds ratios (ORs) were reported.

RESULTS

A weighted total of 14,375 surgeries were included (68.8% in White patients, 16.1% in Black patients, and 15.1% in Hispanic patients; 60.0% private insurance, 26.3% Medicaid, and 13.7% self-pay). Compared with White patients with private insurance, all Black insurance subgroups had longer length of stay (+15.38% to +38.78%, P≤.001), as did Hispanic patients with Medicaid (+28.03%, P<.001), White patients with Medicaid (+13.08%, P<.001), and White patients with self-pay (+9.47%, P=.04). Additionally, compared with White patients with private insurance, decreased odds of institutional discharge were observed for all patients with self-pay (OR, 0.24-0.37, P<.001) as well as White patients with Medicaid (OR, 0.70, P=.003) and Hispanic patients with Medicaid (OR, 0.57, P=.002). There were no significant adjusted associations between race and ethnicity and insurance subgroups and in-hospital complications or time to surgery.

CONCLUSION

These differences in perioperative metrics, primarily for Black patients and patients with self-pay insurance, warrant further examination to identify whether they reflect disparities that should be addressed to promote equitable orthopedic trauma care. [Orthopedics. 2024;47(5):e233-e240.].

Impact of the Comprehensive Care for Joint Replacement Bundled Payment Model on Postoperative Utilization of Home Health and Outpatient Physical Therapy Services

OBJECTIVE

To study the effect of the Comprehensive Care for Joint Replacement (CJR) bundled payment program on postoperative home health and outpatient physical therapy (PT) for total hip or knee arthroplasty (THA/TKA).

DESIGN

Retrospective cohort with national Medicare data (5% claims) using a difference-in-differences analysis comparing January 2013-September 2015 (before) versus October 2016-September 2019 (after).

SETTING

Administrative claims from hospitals in 34 metropolitan statistical areas with mandatory CJR participation as of 2018 and 42 control metropolitan statistical areas.

PARTICIPANTS

Episodes in fee-for-service Medicare beneficiaries (5% claims) undergoing elective THA (n=6327) or TKA (n=10,764) with community discharge.

INTERVENTIONS

Implementation of CJR bundled payment program.

MAIN OUTCOME MEASURES

Home health and outpatient PT, including any use and number of visits.

RESULTS

Program implementation was associated with an increased percentage of THA episodes using home health PT (+8.0 percentage-point change; 95% CI, +3.5 to +12.6; P=.001) but a decreased per-episode number of home health PT visits for THA (-1.1; 95% CI, -1.6 to -0.6; P<.001) and TKA (-1.1; 95% CI, -1.4 to -0.7; P<.001). The program was also associated with an increased per-episode number of outpatient PT visits for TKA in the primary but not sensitivity analyses (+0.8; 95% CI, +0.1 to +1.4; P=.02).

CONCLUSIONS

Findings of increased home health PT may reflect an intentional shift in care from the inpatient postacute setting to the community to decrease costs. Alternatively, the limited effect of CJR, particularly on outpatient PT, could reflect challenges with care coordination in a retrospective bundle spanning multiple care settings.

Adoption of reverse total shoulder arthroplasty for surgical treatment of proximal humerus fractures differs by patient race

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) has gained popularity for the operative treatment of proximal humerus fractures (PHF). The purpose of this study was to compare racial differences in surgical management of PHF between open reduction and internal fixation (ORIF), hemiarthroplasty, and rTSA. Our hypothesis was that there would be no difference in fixation by race.

METHODS

The National Surgical Quality Improvement Program database was queried for ORIF, rTSA, and hemiarthroplasty between 2006 and 2020 for patients with a PHF. Race, ethnicity, age, sex, body mass index, and American Society of Anesthesiologists (ASA) class were recorded. Chi squared tests were performed to assess relationships between patient factors and operative intervention. Factors significant at the 0.10 level in univariable analyses were included in a multivariable multinomial model to predict operative intervention.

RESULTS

Seven thousand four hundred ninety-nine patients underwent surgical treatment for a PHF, including 526 (7%) undergoing hemiarthroplasty, 5011 (67%) undergoing ORIF, and 1962 (26%) undergoing rTSA. 27% of white patients with PHF underwent rTSA compared to 21% of Black patients, 16% of Asian patients, and 14% of Native American and Alaskan Native patients (P < .001). In the multivariable analysis, utilization of rTSA increased over time (OR 1.2 per year since 2006, P < .001) and hemiarthroplasty decreased over time (OR 0.86 per year since 2006, P < .001). Non-White patients had significantly lower odds of undergoing rTSA vs. ORIF (OR 0.75, 95% CI 0.58-0.97), as did male patients (OR 0.77, 95% CI 0.66-0.88). Patients over 65 (OR 3.86, 95% CI 3.39-4.38), patients with higher ASA classifications (ASA2: OR 3.24, 95% CI 1.86-5.66, ASA3: OR 4.77, 95% CI 2.74-8.32, ASA4: OR 5.25, 95% CI 2.89-9.54), and patients who were overweight (OR 1.33, 95% CI 1.14-1.55) or obese (OR 1.52, 95% CI 1.32-1.75) had higher odds of undergoing rTSA vs. ORIF.

DISCUSSION

As utilization of rTSA increases, understanding disparities in surgical treatment of PHF is crucial to improving outcomes and equitable access to emerging orthopedic technologies. While patient factors such as age, body mass index, and comorbidities are known to directly impact outcomes and thus may be predictive of the type of surgical intervention, patient race should not dictate treatment.

Disparities Associated With Total Joint Arthroplasty Transfusion Rates

BACKGROUND

Infections, readmissions, and mortalities after total joint arthroplasty (TJA) are serious complications, and transfusions have been associated with increased complication rates following TJA. Certain populations, including women, Black patients, patients who have public insurance and older adults have higher risks of transfusion. Recently, there has been a decline in transfusion rates and a greater emphasis on equity in medicine. This study examined whether disparities in transfusion rates still exist and what variables influence rates over time.

METHODS

We used a health care system database to identify 5,435 total knee arthroplasty (TKA) and 2,105 total hip arthroplasty (THA) patients from 2013 to 2021. Transfusion rates were 2.9 and 3.1% in the TKA and THA arthroplasty groups, respectively. White race represented 67.1 and 69.8% of the TKA and THA groups, respectively. Fisher exact and Wilcoxon rank sum tests were used to compare categorical and continuous variables. Multivariable logistic regressions were performed to predict transfusion rates within 5 days of surgery and adjust for potential confounders.

RESULTS

Transfusion rates declined over time. However, Black patients had a higher rate of transfusion than White patients despite similar hemoglobin levels, 5.1 versus 1.8% (P < .001) in the TKA group and 4.1 versus 2.7% (P = .103) in the THA group. Following adjustment, the biggest factor associated with a higher transfusion risk in the TKA group was being Black (adjusted odds ratio = 2.2, 95% confidence interval = 1.55 to 3.13).

CONCLUSIONS

Transfusion rates for TJA patients are declining; however, Black patients continued to receive transfusions at higher rates in patients receiving TKA.

Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review

OBJECTIVES

To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions.

BACKGROUND SUMMARY

Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear.

METHODS

A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion.

RESULTS

Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited.

CONCLUSIONS

Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty

BACKGROUND

Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA.

METHODS

There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations.

RESULTS

Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002).

CONCLUSIONS

Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.

Racial Disparities in Periprosthetic Joint Infections after Primary Total Joint Arthroplasty: A Retrospective Study

In the United States, racial disparities have been observed in complications following total joint arthroplasty (TJA), including readmissions and mortality. It is unclear whether such disparities also exist for periprosthetic joint infection (PJI). The clinical data registry of a large New England hospital system was used to identify patients who underwent TJA between January 2018 and December 2021. The comorbidities were evaluated using the Elixhauser Comorbidity Index (ECI). We used Poisson regression to assess the relationship between PJI and race by estimating cumulative incidence ratios (cIRs) and 95% confidence intervals (CIs). We adjusted for age and sex and examined whether ECI was a mediator using structural equation modeling. The final analytic dataset included 10,018 TJAs in 9681 individuals [mean age (SD) 69 (10)]. The majority (96.5%) of the TJAs were performed in non-Hispanic (NH) White individuals. The incidence of PJI was higher among NH Black individuals (3.1%) compared with NH White individuals (1.6%) [adjusted cIR = 2.12, 95%CI = 1.16-3.89; p = 0.015]. Comorbidities significantly mediated the association between race and PJI, accounting for 26% of the total effect of race on PJI incidence. Interventions that increase access to high-quality treatments for comorbidities before and after TJA may reduce racial disparities in PJI.

Periprosthetic Joint Infection: Current Clinical Challenges

Over the last several decades, periprosthetic joint infection has been increasing in incidence and is occurring in more complex patients. While there have been advances in both surgical and medical treatment strategies, there remain important gaps in our understanding. Here, we share our current approaches to the diagnosis and management of periprosthetic joint infection, focusing on frequent clinical challenges and collaborative interdisciplinary care.