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Naylor J, Brady B. Re-imagining rehabilitation after TKA: Towards the provision of fit-for-purpose sustainable models of care and a redefinition of scope. Osteoarthritis Cartilage 2024; 32:473-475. [PMID: 38035976 DOI: 10.1016/j.joca.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Justine Naylor
- Orthopaedic Department, Liverpool Hospital, Sydney, NSW, Australia; South West Sydney Clinical Campuses, School of Clinical Medicine, Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
| | - Bernadette Brady
- Departments of Physiotherapy and Pain Medicine, Liverpool Hospital, Sydney, NSW, Australia; Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; School of Health Sciences, Western Sydney University, Campbelltown, NSW, Australia
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Meckstroth SH, Chapple AG, Dasa V, Krause PC, Leslie LJ, Jones DD. Disparities Associated With Total Joint Arthroplasty Transfusion Rates. J Arthroplasty 2024; 39:600-605. [PMID: 37717830 DOI: 10.1016/j.arth.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023] Open
Abstract
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.
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Affiliation(s)
- Shelby H Meckstroth
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Andrew G Chapple
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Lauren J Leslie
- Department of Orthopaedic Surgery, Ochsner Health Systems, New Orleans, Louisiana
| | - Deryk D Jones
- Department of Orthopaedic Surgery, Ochsner Health Systems, New Orleans, Louisiana
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Adu Y, Hurley J, Ring D. Are There Racial and Ethnic Variations in Patient Attitudes Toward Hip and Knee Arthroplasty for Osteoarthritis? A Systematic Review. Clin Orthop Relat Res 2024:00003086-990000000-01507. [PMID: 38393955 DOI: 10.1097/corr.0000000000003021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND It is not clear why people who identify as Black or Hispanic are less likely to undergo discretionary musculoskeletal surgery such as arthroplasty for osteoarthritis of the hip or knee. Inequities and mistrust are important factors to consider. The role of socioeconomic factors and variation in values, attitudes, and beliefs regarding discretionary procedures are less well understood. A systematic review of the evidence regarding mindsets toward knee and hip arthroplasty among Black and Hispanic people could inform attempts to limit disparities in care. QUESTIONS/PURPOSES In a systematic review of qualitative and quantitative evidence, we asked: (1) What factors are associated with racial and ethnic variations in attitudes toward discretionary hip and knee arthroplasty for osteoarthritis? (2) Do studies that investigate racial and ethnic variations in mindsets toward discretionary orthopaedic care control for potential confounding by socioeconomic factors? METHODS A systematic search of PubMed, Cochrane, and Embase (last searched August 2023) for studies that addressed racial and ethnic variations in mindsets toward discretionary musculoskeletal care use was conducted. We excluded studies that were not published in English, lacked full-text availability, and those that documented patient approaches without comparing them to the willingness to undergo a discretionary procedure. Twenty-one studies were included-14 quantitative and seven qualitative-including 8472 patients. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. The studies included demonstrated low risk of bias: five quantitative studies lacked detail regarding nonresponse bias and one qualitative study lacked details regarding the racial and ethnic composition of its cohort. To answer our first research question, we categorized themes associated with racial differences in mindsets toward discretionary care and recorded the presence of associations in quantitative studies. To answer our second question, we identified whether quantitative studies address potential confounding with socioeconomic factors. There were no randomized trials, so no meta-analysis was performed. RESULTS In general, self-identified Black and Hispanic patients had a lower preference for hip and knee arthroplasty than self-identified White patients. Black patients were more likely to regard osteoarthritis as a natural and irremediable part of aging and prefer home remedies. Both Black and Hispanic patients valued support from religion and were relatively cost-conscious. Black and Hispanic patients had lower perception of benefit, were less familiar with the procedure, had higher levels of fear regarding surgery and recovery, and had more-limited trust in care. Generally, Black and Hispanic social networks tended to address these concerns, whereas White social networks were more likely to discuss the benefits of surgery. Thirteen of 14 quantitative studies considered and accounted for potential confounding socioeconomic variables in their analyses. CONCLUSION The observation that lower preference for discretionary arthroplasty among Black and Hispanic patients is independent from socioeconomic factors and is related to accommodation of aging, preference for agency (home remedies), greater consideration of costs, recovery concerns, and potential harms directs orthopaedic surgeons to find ways to balance equitable access to specialty care and discretionary surgery while avoiding undermining effective accommodation strategies. It is important not to assume that lower use of discretionary surgery represents poorer care or is a surrogate marker for discrimination. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Yaw Adu
- School of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Jack Hurley
- School of Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - David Ring
- Department of Orthopaedic Surgery, Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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4
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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Race. J Arthroplasty 2024:S0883-5403(24)00072-X. [PMID: 38311298 DOI: 10.1016/j.arth.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Goodman SM, Mannstadt I, Gibbons JAB, Rajan M, Bass A, Russell L, Mehta B, Figgie M, Parks ML, Venkatachalam S, Nowell WB, Brantner C, Lui G, Card A, Leung P, Tischler H, Young SR, Navarro-Millán I. Healthcare disparities: patients' perspectives on barriers to joint replacement. BMC Musculoskelet Disord 2023; 24:976. [PMID: 38110904 PMCID: PMC10726517 DOI: 10.1186/s12891-023-07096-0] [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: 05/16/2023] [Accepted: 12/05/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective. METHODS We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor. RESULTS Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important. CONCLUSION We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.
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Affiliation(s)
- Susan M Goodman
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA.
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.
| | - Insa Mannstadt
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - J Alex B Gibbons
- Department of Medicine, Columbia University Vagelos Physician of College and Surgeons, New York, NY, USA
| | - Mangala Rajan
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Anne Bass
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Linda Russell
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Bella Mehta
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Mark Figgie
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Michael L Parks
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | | | | | - Collin Brantner
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Geyanne Lui
- Department of Medicine, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, NY, USA
| | - Andrea Card
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Peggy Leung
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Henry Tischler
- Department of Orthopedic Surgery, New York-Presbyterian Brooklyn Methodist Hospital, New York, NY, USA
| | - Sarah R Young
- Department of Social Work, Binghamton University, Binghamton, NY, USA
| | - Iris Navarro-Millán
- Department of Medicine, Weill Cornell Medicine, New York, NY, 10021, USA
- Department of Rheumatology, Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
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Soares RW, Emara AK, Orr M, Klika AK, Rullán PJ, Pumo TJ, Krebs VE, Molloy RM, Piuzzi NS. When Do We Perform Elective Total Knee Arthroplasty? General and Demographic-Specific Trends of Preoperative Pain and Function among 10,327 Patients. J Knee Surg 2023; 36:1454-1461. [PMID: 36564043 DOI: 10.1055/s-0042-1758774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Total knee arthroplasty (TKA) is the sole disease-modifying intervention for end-stage osteoarthritis. However, the temporal trends and stratification of age and patient demographics of pain and function levels at which surgeons perform TKA have not been characterized. The present investigation aimed to analyze the temporal trends of preoperative pain and functional patient-reported outcomes measures (PROMs) over the past 5 years when stratifying patient demographics. A prospective cohort of all patients who underwent primary elective TKA between January 2016 and December 2020 at a North American integrated tertiary health care system was retrospectively reviewed. The primary outcome was quarterly baseline (preoperative) pain and function PROM values before primary elective TKA. Evaluated PROMs included Knee Osteoarthritis Outcome Score (KOOS)-pain and KOOS-physical function shortform (PS) for the 5-year study period and were stratified by patient demographics (age, sex, race, and body mass index [BMI]). A total of 10,327 patients were analyzed. Preoperative pain levels remained unchanged over the study period for patients in the 45- to 64-year category (P-trend = 0.922). Conversely, there was a significant improvement in preoperative pain levels in the 65+ years group. Sex-stratified trends between males and females did not demonstrate a significant change in pre-TKA baseline pain over the study period (P-trend = 0.347 and P-trend = 0.0744). Both white and black patients demonstrated consistent KOOS-pain levels throughout the study period (P-trend = 0.0855 and P-trend = 0.626). Only white patients demonstrated improving preoperative KOOS-PS (P-trend = 0.0001), while black and "other" patients demonstrated consistent lower preoperative functional levels throughout the study period (P-trend = 0.456 and P-trend = 0.871). All BMI categories demonstrated relatively consistent preoperative KOOS-pain and KOOS-PS except for overweight and obese patients who demonstrated progressive improvement in preoperative KOOS-PS over the study period. Patients and surgeons are electing to perform primary TKA at higher levels of preoperative function. Stratification by race showed black patients did not experience a similar trend of improving function and exhibited a consistently lower functional level versus white patients. This disparity is likely to be multifactorial but may indicate underlying barriers to TKA access.
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Affiliation(s)
- Rui W Soares
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Melissa Orr
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Pedro J Rullán
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Thomas J Pumo
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Benítez TM, Ouyang Z, Khouri AN, Fahmy JN, Wang L, Chung KC. Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture. JAMA Netw Open 2023; 6:e2349621. [PMID: 38153736 PMCID: PMC10755624 DOI: 10.1001/jamanetworkopen.2023.49621] [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: 08/16/2023] [Accepted: 10/31/2023] [Indexed: 12/29/2023] Open
Abstract
Importance Medicare provides near-universal health insurance to US residents aged 65 years or older. How eligibility for Medicare coverage affects racial and ethnic disparities in operative management after orthopedic trauma is poorly understood. Objective To assess the association of Medicare eligibility with racial and ethnic disparities in open reduction and internal fixation (ORIF) after distal radius fracture (DRF). Design, Setting, and Participants This retrospective cohort study with a regression discontinuity design obtained data from the Healthcare Cost and Utilization Project all-payer statewide databases for Florida, Maryland, and New York. These databases contain encounter-level data and unique patient identifiers for longitudinal follow-up across emergency departments, outpatient surgical centers, and hospitals. The cohort included patients aged 57 to 72 years who sustained DRFs between January 1, 2016, and November 30, 2019. Data analysis was performed between March 1 and October 15, 2023. Exposure Eligibility for Medicare coverage at age 65 years. Main Outcomes and Measures Type of management for DRF (closed treatment, external fixation, percutaneous pinning, and ORIF). Time to surgery was ascertained in patients undergoing ORIF. Multivariable logistic regression and regression discontinuity design were used to compare racial and ethnic disparities in patients who underwent ORIF before or after age 65 years. Results A total of 26 874 patients with DRF were included (mean [SD] age, 64.6 [4.6] years; 22 359 were females [83.2%]). Of these patients, 2805 were Hispanic or Latino (10.4%; hereafter, Hispanic), 1492 were non-Hispanic Black (5.6%; hereafter, Black), and 20 548 were non-Hispanic White (76.5%; hereafter, White) and 2029 (7.6%) were individuals of other races and ethnicities (including Asian or Pacific Islander, Native American, and other races). Overall, 32.6% of patients received ORIF but significantly lower use was observed in Black (20.2% vs 35.4%; P < .001) and Hispanic (25.8% vs 35.4%; P < .001) patients compared with White individuals. After adjusting for potential confounders, multivariable logistic regression analysis confirmed the disparity in ORIF use in Black (odds ratio [OR], 0.60; 95% CI, 0.50-0.72) and Hispanic patients (OR, 0.82; 95% CI, 0.72-0.94) compared with White patients. No significant difference in ORIF use was found among racial and ethnic groups at age 65 years. The expected disparity in ORIF use between White and Black patients at age 65 years without Medicare coverage was 12.6 percentage points; however, the actual disparity was 22.0 percentage points, 9.4 percentage points (95% CI, 0.3-18.4 percentage points) greater than expected, a 75% increase (P = .04). In the absence of Medicare coverage, the expected disparity in ORIF use between White and Hispanic patients was 8.3 percentage points, and this result persisted without significant change in the presence of Medicare coverage. Conclusions and Relevance Results of this study showed that surgical management for DRF was popular in adults aged 57 to 72 years, but there was lower ORIF use in racial or ethnic minority patients. Medicare eligibility at age 65 years did not attenuate race and ethnicity-based disparities in surgical management of DRFs.
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Affiliation(s)
- Trista M. Benítez
- University of Michigan Medical School, Ann Arbor
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Zhongzhe Ouyang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Alexander N. Khouri
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Joseph N. Fahmy
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Gupta P, Palosaari A, Quan T, Ifarraguerri AM, Tabaie S. Evaluating the association between race and complications following pediatric upper extremity surgery. J Pediatr Orthop B 2023; 32:553-556. [PMID: 36912085 DOI: 10.1097/bpb.0000000000001073] [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: 03/14/2023]
Abstract
Race can influence perioperative care and outcomes in adult and pediatric orthopedic surgery. However, no prior study has evaluated any associations between race and complications following upper extremity surgery in pediatric patients. Thus, the purpose of this study was to evaluate whether there are any differences in risks for complications, readmission, or mortality following upper extremity surgery between African American and Caucasian pediatric patients. Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were categorized into two cohorts: patients who were Caucasian and patients who were African American. Differences in demographics, comorbidities, and postoperative complications were assessed and compared between the two-patient population using bivariate and multivariable regression analyses. Of the 25 848 pediatric patients who underwent upper extremity surgeries, 21 693 (83.9%) were Caucasian, and 4155 (16.1%) were African American. Compared to Caucasian patients, African American patients were more likely to have a higher American Society of Anesthesiologists classification ( P < 0.001), as well as pulmonary comorbidities ( P < 0.001) and hematologic disorders ( P = 0.004). Following adjustment on multivariable regression analysis to control for baseline characteristics, there were no differences in any postoperative complications between Caucasian and African American patients. In conclusion, African American pediatric patients are not at an increased risk for postoperative complications compared to Caucasian patients following upper extremity surgery. Race should not be used independently when evaluating patient risk for postoperative complications. Level of Evidence: III.
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Affiliation(s)
- Puneet Gupta
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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9
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Hinman AD, Royse KE, Chan PH, Paxton EW, Navarro RA. Association Between Race/Ethnicity and 90-Day Emergency Department Visits in Patients Undergoing Elective Total Knee Arthroplasty or Total Hip Arthroplasty in a Universally Insured Population. J Arthroplasty 2023; 38:2210-2219.e1. [PMID: 37479196 DOI: 10.1016/j.arth.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Research has identified disparities in returns to care by race/ethnicity following primary total joint arthroplasty. We sought to identify risk factors for 90-day emergency department (ED) returns following primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) for these populations. METHODS Black, Hispanic, and non-Hispanic White patients who underwent elective primary unilateral TKA and THA in an integrated US healthcare system were identified. Risk factors for 90-day postoperative ED visits including patient demographics, household income and education, comorbidities, preoperative healthcare utilization, and copay data were identified with multivariable logistic regression. RESULTS Postoperative 90-day ED visits occurred in 13.3% of 79,565 TKA patients (17.2% Black; 14.9% Hispanic; 12.5% White) and 11.0% of THA patients (13.4% Black; 12.1% Hispanic; 10.7% White). Across racial/ethnic categories, patients who had an ED visit within 1 year of their TKA or THA date were more likely to have a 90-day ED return. Shared risk factors for TKA patients were chronic lung disease and outpatient utilization (25th and 75th percentile), while peripheral vascular disease was a shared risk factor for THA patients. Risk factors for multiple races of TKA and THA patients included depression, drug abuse, and psychosis. Prior copay for White (TKA) and Hispanic (TKA and THA) patients was protective, while preoperative primary care was protective for Black THA patients. CONCLUSION Future strategies to reduce postoperative ED returns should include directed patient outreach for patients who had ED visits and mental health in the year prior to TKA and THA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Kathryn E Royse
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Priscilla H Chan
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Ronald A Navarro
- Department of Orthopaedics, Southern California Permanente Medical Group, South Bay, California
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10
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Dubin JA, Bains SS, Chen Z, Salib CG, Nace J, Mont MA, Delanois RE. Race Associated With Increased Complication Rates After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2220-2225. [PMID: 37172792 DOI: 10.1016/j.arth.2023.04.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications. METHODS A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients. RESULTS The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455). CONCLUSION Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.
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Affiliation(s)
- Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Christopher G Salib
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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11
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Mirza SZ, Zhang Y, Do HT, Mehta B, Goodman SM, Bass AR. Black Patients are More Likely to Undergo Early Revision Total Knee Arthroplasty in a Matched Cohort Regardless of Surgeon Experience. J Arthroplasty 2023; 38:2226-2231.e14. [PMID: 37295621 DOI: 10.1016/j.arth.2023.05.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Black patients are at an increased risk of aseptic revision total knee arthroplasty (TKA) when compared to White patients. The goal of this study was to determine whether racial disparities in revision TKA risk are related to surgeon characteristics. METHODS This was an observational cohort study. We used inpatient administrative data to identify Black patients who underwent unilateral primary TKA in New York State. There were 21,948 Black patients who were matched 1:1 to White patients on age, sex, ethnicity, and insurance type. The primary outcome was aseptic revision TKA within 2 years of primary TKA. We calculated annual surgeon TKA volume and identified surgeon characteristics such as training in North America, board certification, and years of experience. RESULTS Black patients had a higher odds of aseptic revision TKA (odds ratio (OR) 1.32, 95% CI 1.12-1.54, P < .001) and were disproportionately cared for by low volume surgeons (≤12 TKA/year). The relationship between low volume surgeons and risk of aseptic revision was not statistically significant (OR 1.24, 95% CI 0.72-2.11, P = .436). The adjusted odds ratio (aOR) for aseptic revision TKA in Black versus White patients varied across surgeon/hospital TKA volume category pairs, with the greatest aOR when TKA were performed by the highest volume surgeons at the highest volume hospitals (aOR 2.8, 95% CI 0.98- 8.09, P = .055). CONCLUSION Black patients were more likely to undergo aseptic TKA revision than matched White patients. This disparity was not explained by surgeon characteristics.
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Affiliation(s)
- Serene Z Mirza
- Touro College of Osteopathic Medicine, New York, New York
| | - Yi Zhang
- Department of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Huong T Do
- Department of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Bella Mehta
- Department of Rheumatology, Hospital for Special Surgery, New York, New York; Department of Rheumatology, Weill Cornell Medicine, New York, New York
| | - Susan M Goodman
- Department of Rheumatology, Hospital for Special Surgery, New York, New York; Department of Rheumatology, Weill Cornell Medicine, New York, New York
| | - Anne R Bass
- Department of Rheumatology, Hospital for Special Surgery, New York, New York; Department of Rheumatology, Weill Cornell Medicine, New York, New York
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Schmerler J, Dhanjani SA, Wenzel A, Kurian SJ, Srikumaran U, Ficke JR. Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis. J Foot Ankle Surg 2023; 62:928-932. [PMID: 37595678 DOI: 10.1053/j.jfas.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/01/2023] [Accepted: 08/13/2023] [Indexed: 08/20/2023]
Abstract
Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.
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Affiliation(s)
| | - Suraj A Dhanjani
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alyssa Wenzel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shyam J Kurian
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Umasuthan Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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13
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Tarawneh OH, Quan T, Liu IZ, Pizzarro J, Marquardt C, Tabaie SA. Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2847-2852. [PMID: 36853514 DOI: 10.1007/s00590-023-03496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. METHODS Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. RESULTS Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. CONCLUSION Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.
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Affiliation(s)
- Omar H Tarawneh
- School of Medicine, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA.
| | - Theodore Quan
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Ivan Z Liu
- The Medical College of Georgia, Augusta University, 1120 15th St, GA, 30912, Augusta, USA
| | - Jordan Pizzarro
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Caillin Marquardt
- Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, 2300 M St, Washington DC, Washington, DC, 20037, USA
| | - Sean A Tabaie
- Department of Orthopaedic Surgery, Children's National Hospital, 111 Michigan Avenue, Washington, NWDC, 20010, USA
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Joo PY, Halperin SJ, Dhodapkar MM, Adeclat GJ, Elaydi A, Wilhelm C, Grauer JN. Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population. Hand (N Y) 2023:15589447231198267. [PMID: 37737570 DOI: 10.1177/15589447231198267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE Level III-Retrospective review of national database.
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Affiliation(s)
| | | | | | | | - Ali Elaydi
- Yale School of Medicine, New Haven, CT, USA
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15
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Vij N, Bingham J, Chen A, Irwin C, Leber C, Schwartz K, Schmidt K. Race and Sex Disparities in Lower Extremity Total Joint Arthroplasty: A Retrospective Database Study. Cureus 2023; 15:e42485. [PMID: 37637575 PMCID: PMC10452050 DOI: 10.7759/cureus.42485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
INTRODUCTION Total joint arthroplasty (TJA) is successful in improving health-related quality of life. However, outcomes vary in the literature due to modifiable and non-modifiable factors. Modifiable factors consist of body mass index (BMI), nutrition, and tobacco use. Non-modifiable risk factors include age, race, sex, and socioeconomic status. Prior literature has focused on racial disparities in terms of the utilization of lower extremity arthroplasty. The purpose of this study is to determine the effect of race and sex on the in-hospital complication rate, length of stay, and charges associated with primary TJA. METHODS This retrospective cohort utilized complex survey data from the National Inpatient Sample (NIS) between 2016 and 2019. The use of the International Classification of Disease-10 Procedure Codes (ICD-10 PCS) for right hip, left hip, right knee, and left knee TJA yielded a preliminary total of 2,660,280 patients. The exclusion criteria were bilateral arthroplasty and concomitant unilateral hip and knee arthritis. Major complications were defined as acute myocardial infarction, cardiac arrest, pulmonary embolism, adult respiratory distress syndrome, stroke, shock, and septicemia. Odds ratio (OR) and beta coefficients were adjusted for age, sex, primary payer, hospital region, hospital teaching status, and year. Total charges were adjusted for inflation using the Consumer Price Index data reported by the US Bureau of Labor Statistics. RESULTS A total of 2,589,510 patients met our inclusion criteria; 87.6%, 5.9%, 4.8%, 1.4%, and 0.3% of people were 'White', 'Black', 'Hispanic', 'Asian, or Pacific Islander', and 'Native American', as defined by the National (Nationwide) Inpatient Sample (NIS) Variable 'RACE'. Black individuals experienced a significantly greater major complication rate compared to White individuals (0.87% vs. 0.74%, OR 1.25, p-value = 0.0004). Black and Hispanic individuals experienced a significantly greater minor complication rate compared to White individuals (6.39% vs. 4.12%, odds ratio (OR) 1.61, p-value < 0.0001; 4.68% vs. 4.12%, OR 1.17, p-value < 0.0001). Black, Hispanic, Asian or Pacific Islander, and Native American individuals stayed, on average, 0.33, 0.19, 0.19, and 0.25 days longer than White individuals (2.78, 2.54, 2.55, 2.56 vs. 2.37 days, p<0.0001). None of these statistically significant differences exceeded the established minimal clinically important difference of two days. Black, Hispanic, and Asian or Pacific Islander patients were charged $5,751, $18,656, and $12,119 more than White patients ($72,122, $85,027, $78,490, and $59,297 vs. $66,371, p ≤ 0.0165). Native American patients were charged $7,074 less than White patients ($59,297 vs. $66,371, p < 0.0001). CONCLUSIONS Black and Hispanic TJA patients may have higher complication rates than White TJA patients. The differences in length of stay between race groups may not affect outcomes. Hispanic patients received significantly more charges than White patients, and Native American patients received significantly fewer charges than White patients after controlling for non-modifiable risk factors. Addressing the charge disparities may reduce the total national cost burden associated with TJA. The present study highlights the need for further studies on healthcare outcomes related to race and sex.
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Affiliation(s)
- Neeraj Vij
- Department of Orthopaedic Surgery, University of Kansas School of Medicine - Wichita, Wichita, USA
| | - Joshua Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, USA
| | - Antonia Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, USA
| | - Chase Irwin
- Department of Biostatistics, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Christian Leber
- Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Kendall Schwartz
- Department of Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Kenneth Schmidt
- Department of Orthopaedic Surgery, OrthoArizona, Phoenix, USA
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16
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Zareef U, Paul RW, Sudah SY, Erickson BJ, Menendez ME. Influence of Race on Utilization and Outcomes in Shoulder Arthroplasty: A Systematic Review. JBJS Rev 2023; 11:01874474-202306000-00015. [PMID: 37335835 DOI: 10.2106/jbjs.rvw.23.00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Studies have shown that utilization and outcomes after shoulder arthroplasty vary by sociodemographic factors, highlighting disparities in care. This systematic review synthesized all available literature regarding the relationship between utilization and outcomes of shoulder arthroplasty and race/ethnicity. METHODS Studies were identified using PubMed, MEDLINE (through Ovid), and CINAHL databases. All English language studies of Level I through IV evidence that specifically evaluated utilization and/or outcomes of hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty by race and/or ethnicity were included. Outcomes of interest included rates of utilization, readmission, reoperation, revision, and complications. RESULTS Twenty-eight studies met inclusion criteria. Since the 1990s, Black and Hispanic patients have demonstrated a lower utilization rate of shoulder arthroplasty compared with White patients. Although utilization has increased among all racial groups throughout the present decade, the rate of increase is greater for White patients. These differences persist in both low-volume and high-volume centers and are independent of insurance status. Compared with White patients, Black patients have a longer postoperative length of stay after shoulder arthroplasty, worse preoperative and postoperative range of motion, a higher likelihood of 90-day emergency department visits, and a higher rate of postoperative complications including venous thromboembolism, pulmonary embolism, myocardial infarction, acute renal failure, and sepsis. Patient-reported outcomes, including the American Shoulder and Elbow Surgeon's score, did not differ between Black and White patients. Hispanics had a significantly lower revision risk compared with White patients. One-year mortality did not differ significantly between Asians, Black patients, White patients, and Hispanics. CONCLUSION Shoulder arthroplasty utilization and outcomes vary by race and ethnicity. These differences may be partly due to patient factors such as cultural beliefs, preoperative pathology, and access to care, as well as provider factors such as cultural competence and knowledge of health care disparities. LEVEL OF EVIDENCE Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Usman Zareef
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ryan W Paul
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Suleiman Y Sudah
- Department of Orthopaedic Surgery, Rutgers Health Monmouth Medical Center, Long Branch, New Jersey
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, New York, New York
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Woelber E, Rana AJ, Springer BD, Kerr JM, Courtney PM, Krueger CA. Health Policy Views and Political Advocacy of Arthroplasty Surgeons: A Survey of the American Association of Hip and Knee Surgeons Members. J Arthroplasty 2023:S0883-5403(23)00091-8. [PMID: 36773663 DOI: 10.1016/j.arth.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/24/2023] [Accepted: 02/01/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND The American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation. METHODS A 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics. RESULTS There were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%). CONCLUSION Responding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.
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Affiliation(s)
- Erik Woelber
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam J Rana
- Department of Orthopaedics & Sports Medicine, Maine Medical Partners, South Portland, Maine
| | | | - Joshua M Kerr
- American Association of Hip and Knee Surgeons, Chicago, Illinois
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Hadad MJ, Rullán-Oliver P, Grits D, Zhang C, Emara AK, Molloy RM, Klika AK, Piuzzi NS. Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients. Clin Orthop Relat Res 2023; 481:254-264. [PMID: 36103368 PMCID: PMC9831172 DOI: 10.1097/corr.0000000000002392] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/11/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address. QUESTIONS/PURPOSES The goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes. METHODS Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-day inpatient readmission, and 90-day ED admission, while adjusting for age, gender, BMI, smoking, CCI, and insurance. This was followed by a mediation analysis that explored whether the association between race (the independent variable) and measured outcomes (the dependent variables) could be partially or completely attributable to confounding from the ADI (the mediator, in this model). The mediation effect was measured as a percentage of the total effect of race on the outcomes of interest that was mediated by ADI. RESULTS In the THA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.43 [95% confidence interval (CI) 0.31 to 0.59]; p < 0.001) and nonhome discharge (OR 0.39 [95% CI 0.27 to 0.56]; p < 0.001). In mediation analysis, ADI partially explained (or mediated) 37% of the association between race and LOS of 3 days or more (-0.043 [95% CI -0.063 to -0.026]; p < 0.001) and 40% of the association between race and nonhome discharge (0.041 [95% CI 0.024 to 0.059]; p < 0.001). However, a smaller direct association between race and both outcomes was observed (LOS 3 days or more: -0.075 [95% CI -0.13 to -0.024]; p = 0.004; nonhome discharge: 0.060 [95% CI 0.016 to 0.11]; p = 0.004). No association was observed between race and 90-day readmission or ED admission in the THA group. In the TKA group, after adjusting for age, gender, BMI, smoking, CCI, and insurance, White patients had lower odds of experiencing an LOS of 3 days or more (OR 0.41 [95% CI 0.32 to 0.54]; p < 0.001), nonhome discharge (OR 0.44 [95% CI 0.33 to 0.60]; p < 0.001), 90-day readmission (OR 0.54 [95% CI 0.39 to 0.77]; p < 0.001), and 90-day ED admission (OR 0.60 [95% CI 0.45 to 0.79]; p < 0.001). In mediation analysis, ADI mediated 19% of the association between race and LOS of 3 days or more (-0.021 [95% CI -0.035 to -0.007]; p = 0.004) and 38% of the association between race and nonhome discharge (0.029 [95% CI -0.016 to 0.040]; p < 0.001), but there was also a direct association between race and these outcomes (LOS 3 days or more: -0.088 [95% CI -0.13 to -0.049]; p < 0.001; nonhome discharge: 0.046 [95% CI 0.014 to 0.078]; p = 0.006). ADI did not mediate the associations observed between race and 90-day readmission and ED admission in the TKA group. CONCLUSION Our findings suggest that socioeconomic disadvantage may be implicated in a substantial proportion of the previously assumed race-driven disparity in healthcare utilization parameters after primary total joint arthroplasty. Orthopaedic surgeons should attempt to identify potentially modifiable socioeconomic disadvantage indicators. This serves as a call to action for the orthopaedic community to consider specific interventions to support patients from vulnerable areas or whose incomes are lower, such as supporting applications for nonemergent medical transportation or referring patients to local care coordination agencies. Future studies should seek to identify which specific resources or approaches improve outcomes after TJA in patients with socioeconomic disadvantage. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Matthew J. Hadad
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Pedro Rullán-Oliver
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chao Zhang
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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19
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Gender and outcomes in total joint arthroplasty: a systematic review on healthcare disparities in the United States. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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