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Amen TB, Akosman I, Subramanian T, Johnson MA, Rudisill SS, Song J, Maayan O, Barber LA, Lovecchio FC, Qureshi S. Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting. Spine J 2024; 24:1361-1368. [PMID: 38301902 DOI: 10.1016/j.spinee.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND CONTEXT Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated. PURPOSE This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021. OUTCOME MEASURES Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality. METHODS A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences. RESULTS Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all). CONCLUSIONS Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.
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Affiliation(s)
- Troy B Amen
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Izzet Akosman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Tejas Subramanian
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Mitchell A Johnson
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Samuel S Rudisill
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Junho Song
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Omri Maayan
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Lauren A Barber
- Visiting Fellow at St. George and Sutherland Clinical School, University of New South Wales Medicine, Sydney, NSW 2052, Australia
| | | | - Sheeraz Qureshi
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Rudisill SS, Hornung AL, Akosman I, Amen TB, Lovecchio FC, Nwachukwu BU. Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting? J Shoulder Elbow Surg 2024; 33:1536-1546. [PMID: 38182016 DOI: 10.1016/j.jse.2023.11.008] [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: 07/24/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.
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Affiliation(s)
| | - Alexander L Hornung
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Francis C Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Silvestre J, Ahn J, Dehghan N, Gitajn IL, Slobogean GP, Harris MB. Analysis of the diversity pipeline for the orthopedic trauma surgeon workforce in the United States. Injury 2024; 55:111695. [PMID: 38959676 DOI: 10.1016/j.injury.2024.111695] [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: 01/28/2024] [Revised: 05/23/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION There is a lack of research on the state of racial, ethnic, and gender diversity in the emerging orthopedic trauma workforce. The purpose of this study was to analyze the training pathway for diverse candidates in orthopedic trauma as it relates to race, ethnicity, and sex. METHODS Self-reported demographic data were compared among allopathic medical students, orthopedic surgery residents, orthopedic trauma fellows, and the general population in the United States (2013-2022). Race categories consisted of White, Asian, Black, and Native American/Alaskan Native (NA/AN), and Native Hawaiian/Pacific Islander (NH/PI). Ethnicity categories were Hispanic/Latino or non-Hispanic/Latino. Sex categories were male and female. Representation was calculated at each stage of accredited training. Participation-to-prevalence ratios (PPRs) quantified the equitable representation of demographic groups in the emerging orthopedic trauma workforce relative to the US population. PPR thresholds were used to classify representation as overrepresented (PPR > 1.2), equitable (PPR = 0.8-1.2), and underrepresented (PPR < 0.8). RESULTS Relative to medical school and orthopedic surgery residency, fewer female (48.5 % vs 16.7 % vs 18.7 %, P < 0.001), Hispanic (6.1 % vs 4.5 % vs 2.6 %, P < 0.001), Black (6.9 % vs 5.0 % vs 3.1 %, P < 0.001), and Asian (24.0 % vs 14.3 % vs 12.2 %, P < 0.001) trainees existed in orthopedic trauma fellowship training. In contrast, more male (51.5 % vs 83.3 % vs 81.3 %, P < 0.001) and White (62.8 % vs 79.1 % vs 84.0 %, P < 0.001) trainees existed in orthopedic trauma fellowship relative to earlier training stages. There were zero NA/AN or NH/PI trainees in orthopedic trauma (PPR = 0). Relative to the US population, Hispanic (PPR = 0.14), Black (PPR = 0.25), and female (PPR = 0.37) trainees were underrepresented in orthopedic trauma. In contrast, Asian (PPR = 2.04), male (PPR = 1.64), and White (PPR = 1.36) trainees were overrepresented in orthopedic trauma. CONCLUSION Women, racial, and ethnic minorities are underrepresented in the emerging orthopedic trauma workforce relative to the US population, and earlier stages of training. Targeted recruitment and guided mentorship of these groups may lead to greater interest, engagement, and diversity in orthopedic trauma.
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Affiliation(s)
- Jason Silvestre
- Medical University of South Carolina, Charleston, SC, United States.
| | - Jaimo Ahn
- University of Michigan Medical School, Ann Arbor, MI, United States
| | - Niloofar Dehghan
- University of Arizona College of Medicine Phoenix, Phoenix, AZ, United States
| | - Ida L Gitajn
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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Okewunmi J, Stern BZ, Arroyave Villada JS, Restrepo Mejia M, Zubizarreta N, Poeran J, Forsh DA. Differences in Perioperative Metrics by Race and Ethnicity and Insurance After Pelvic Fracture: A Nationwide Study. Orthopedics 2024:1-8. [PMID: 38864645 DOI: 10.3928/01477447-20240605-03] [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] [Indexed: 06/13/2024]
Abstract
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. 202x;4x(x):xx-xx.].
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Mora R, Maze M. The role of cultural competency training to address health disparities in surgical settings. Br Med Bull 2024; 150:42-59. [PMID: 38465857 DOI: 10.1093/bmb/ldae005] [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] [Accepted: 02/16/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities. SOURCES OF DATA In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities. AREAS OF AGREEMENT The unjustness of health care disparities is universally accepted. AREAS OF CONTROVERSY Whether the outcome of CCT justifies the cost has not been effectively answered. GROWING POINTS These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting. AREAS TIMELY FOR DEVELOPING RESEARCH Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.
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Affiliation(s)
- Roberto Mora
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Dhanjani SA, Gomez G, Rogers D, LaPorte D. Are There Racial and Ethnic Disparities in Management and Outcomes of Surgically Treated Distal Radius Fractures? Hand (N Y) 2024; 19:471-480. [PMID: 36196925 PMCID: PMC11067843 DOI: 10.1177/15589447221124248] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Racial/ethnic disparities have been demonstrated across multiple orthopedic sub-specialties. There is a paucity of literature examining disparities in distal radius fracture (DRF) management. METHODS Using the National Surgical Quality Improvement Program database, we analyzed 15 559 non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic adults who underwent open reduction and internal fixation for DRF from 2013 to 2019. We evaluated time from hospital admission to surgery and length of stay using Poisson regression. Deep venous thrombosis, pulmonary embolism (PE), and wound complications were reported using descriptive statistics. Thirty-day reoperation and readmission were analyzed using binary logistic regression. RESULTS Wait time to surgery was longer for Hispanic patients than NH White patients (incidence rate ratio [IRR]: 2.54, P < .001); this narrowed over time (IRR: 0.944, P = .047). Length of stay was longer for NH Black (IRR: 1.78, P < .001) and Hispanic patients (IRR: 1.83, P < .001), but shorter for NH Asian (IRR: 0.715, P = .019) than NH White patients; this temporally narrowed for NH Black patients (IRR: 0.908, P = .001). Deep venous thrombosis, PE, and wound complications occurred at a rate less than 0.30% across all groups. Hispanic patients were less likely to undergo reoperation than NH White patients (odds ratio [OR]: 0.254, P = .003). While there was no difference in readmission between groups in the aggregated study period, NH Black patients experienced a temporal increase in readmissions relative to NH White patients (OR: 1.40, P = .038). CONCLUSIONS Racial and ethnic disparities exist in DRF management. Further investigation on causes for and solutions to combat these disparities in DRF care may help improve the inequities observed.
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Affiliation(s)
| | - Gabriela Gomez
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Davis Rogers
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dawn LaPorte
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bernstein DN, Shin D, Poolman RW, Schwab JH, Tobert DG. Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores? Clin Orthop Relat Res 2024; 482:604-614. [PMID: 37882798 PMCID: PMC10937004 DOI: 10.1097/corr.0000000000002896] [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: 03/25/2023] [Accepted: 09/20/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate. QUESTIONS/PURPOSES Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors? METHODS New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status-as measured by the SDoH indices-among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05. RESULTS There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively. CONCLUSION Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application. CLINICAL RELEVANCE We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - David Shin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf W. Poolman
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Wang Y, Jiang Q, Long H, Chen H, Wei J, Li X, Wang H, Xie D, Zeng C, Lei G. Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study. Int J Surg 2024; 110:1347-1355. [PMID: 38320106 PMCID: PMC10942226 DOI: 10.1097/js9.0000000000000794] [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: 05/10/2023] [Accepted: 09/10/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Limited studies have examined the benefits of early arthroplasty within 48 h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48 h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns. MATERIALS AND METHODS This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty. RESULTS During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11 731 pairs receiving THA and 13 568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA. CONCLUSION Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.
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Affiliation(s)
| | | | | | - Hu Chen
- Tibet Autonomous Region People’s Hospital, Lhasa, Tibet, People’s Republic of China
| | - Jie Wei
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Health Management Center, Xiangya Hospital
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Xiaoxiao Li
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong
| | | | - Chao Zeng
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Guanghua Lei
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
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Chakraborty A, Zhuang T, Shapiro LM, Amanatullah DF, Kamal RN. Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance? J Arthroplasty 2024; 39:606-611.e6. [PMID: 37778640 DOI: 10.1016/j.arth.2023.09.029] [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: 05/04/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. METHODS Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. RESULTS Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). CONCLUSIONS Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.
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Affiliation(s)
- Aritra Chakraborty
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Thompson Zhuang
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
| | - Robin N Kamal
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University School of Medicine, Redwood City, California
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10
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Subramanian T, Akosman I, Amen TB, Pajak A, Kumar N, Kaidi A, Araghi K, Shahi P, Asada T, Qureshi SA, Iyer S. Comparison of the Safety of Inpatient Versus Outpatient Lumbar Fusion : A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2024; 49:269-277. [PMID: 37767789 DOI: 10.1097/brs.0000000000004838] [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: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The objective of this study is to synthesize the early data regarding and analyze the safety profile of outpatient lumbar fusion. SUMMARY OF BACKGROUND DATA Performing lumbar fusion in an outpatient or ambulatory setting is becoming an increasingly employed strategy to provide effective value-based care. As this is an emerging option for surgeons to employ in their practices, the data is still in its infancy. METHODS This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that described outcomes of inpatient and outpatient lumbar fusion cohorts were searched from PubMed, Medline, The Cochrane Library, and Embase. Rates of individual medical and surgical complications, readmission, and reoperation were collected when applicable. Patient-reported outcomes (PROMs) were additionally collected if reported. Individual pooled comparative meta-analysis was performed for outcomes of medical complications, surgical complications, readmission, and reoperation. PROMs were reviewed and qualitatively reported. RESULTS The search yielded 14 publications that compared outpatient and inpatient cohorts with a total of 75,627 patients. Odds of readmission demonstrated no significant difference between outpatient and inpatient cohorts [OR=0.94 (0.81-1.11)]. Revision surgery similarly was no different between the cohorts [OR=0.81 (0.57-1.15)]. Pooled medical and surgical complications demonstrated significantly decreased odds for outpatient cohorts compared with inpatient cohorts [OR=0.58 (0.34-0.50), OR=0.41 (0.50-0.68), respectively]. PROM measures were largely the same between the cohorts when reported, with few studies showing better ODI and VAS Leg outcomes among outpatient cohorts compared with inpatient cohorts. CONCLUSION Preliminary data regarding the safety of outpatient lumbar fusion demonstrates a favorable safety profile in appropriately selected patients, with PROMs remaining comparable in this setting. There is no data in the form of prospective and randomized trials which is necessary to definitively change practice.
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Affiliation(s)
- Tejas Subramanian
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Izzet Akosman
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Troy B Amen
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Anthony Pajak
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Austin Kaidi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Tomoyuki Asada
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
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11
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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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Schloemann DT, Ricciardi BF, Thirukumaran CP. Disparities in the Epidemiology and Management of Fragility Hip Fractures. Curr Osteoporos Rep 2023; 21:567-577. [PMID: 37358663 DOI: 10.1007/s11914-023-00806-6] [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] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize the recently published scientific evidence on disparities in epidemiology and management of fragility hip fractures. RECENT FINDINGS There have been a number of investigations focusing on the presence of disparities in the epidemiology and management of fragility hip fractures. Race-, sex-, geographic-, socioeconomic-, and comorbidity-based disparities have been the primary focus of these investigations. Comparatively fewer studies have focused on why these disparities may exist and interventions to reduce disparities. There are widespread and profound disparities in the epidemiology and management of fragility hip fractures. More studies are needed to understand why these disparities exist and how they can be addressed.
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Affiliation(s)
- Derek T Schloemann
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
| | - Benjamin F Ricciardi
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Caroline P Thirukumaran
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
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13
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Kerluku J, Walker P, Amen T, Almeida BA, McColgan R, Urruela A, Nguyen J, Fufa DT. Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release. J Bone Joint Surg Am 2023; 105:1442-1449. [PMID: 37406133 DOI: 10.2106/jbjs.22.01045] [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: 07/07/2023]
Abstract
BACKGROUND Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity. METHODS Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery. RESULTS The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively). CONCLUSIONS Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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14
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Amen TB, Chatterjee A, Dekhne M, Rudisill SS, Subramanian T, Song J, Kazarian GS, Morse KW, Iyer S, Qureshi S. Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State. Spine (Phila Pa 1976) 2023; 48:1282-1288. [PMID: 37249380 DOI: 10.1097/brs.0000000000004736] [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: 02/14/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State. SUMMARY OF BACKGROUND DATA Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity. MATERIALS AND METHODS We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity. RESULTS Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001). CONCLUSIONS We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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15
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Martinez VH, Quirarte JA, Treffalls RN, McCormick S, Martin CW, Brady CI. In-Hospital Mortality Risk and Discharge Disposition Following Hip Fractures: An Analysis of the Texas Trauma Registry. Geriatr Orthop Surg Rehabil 2023; 14:21514593231200797. [PMID: 37701926 PMCID: PMC10493052 DOI: 10.1177/21514593231200797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Background In-hospital mortality and discharge disposition following traumatic hip fractures previously reported in the literature, has mainly focused on a nationwide scale, which may not be reflective of unique populations. Objective Our aim was to characterize demographics, hospital disposition, and associated outcomes for patients with the most common hip fractures. Methods A retrospective study utilizing the Trauma Registry from the Texas Department of State Health Services. Patient demographics, injury characteristics, and outcomes, such as in-hospital mortality, and discharge dispositions, were collected. The data were analyzed via univariate analysis and multivariate regressions. Results There were 17,104 included patients, composed of 45% femoral neck fractures (FN) and 55% intertrochanteric fractures (IT). There were no differences in injury severity score (ISS) (9 ± 1.8) or age (77.4 ± 8 years old) between fracture types. In-hospital mortality risk was low but different among fracture types (intertrochanteric, 1.9% vs femoral neck, 1.3%, P = .004). However, when controlling for age, and ISS, intertrochanteric fractures and Hispanic patients were associated with higher mortality (P < .001, OR 1.5, 95% CI 1.1-2.0). Uninsured, and Black/African American (P = .05, OR 1.2, 95% CI 1.1-1.3) and Hispanic (P < .001, OR 1.2, 95% CI 1.1-1.3) patients were more likely to be discharged home after adjusting for age, ISS, and payment method. Conclusion Regardless of age, severity of the injury or admission hemodynamics, intertrochanteric fractures and Hispanic/Latino patients had an increased risk of in-hospital mortality. Patients who were uninsured, Hispanic, or Black were discharged home rather than to rehabilitation, regardless of age, ISS, or payment method.
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Affiliation(s)
- Victor H. Martinez
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
| | - Jaime A. Quirarte
- University of Texas Health Science Center at Houston Department of Orthopedic Surgery, Houston, TX, USA
| | - Rebecca N. Treffalls
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA
| | - Sekinat McCormick
- UT Health San Antonio Department of Orthopaedics, San Antonio, TX, USA
| | - Case W. Martin
- UT Health San Antonio Department of Orthopaedics, San Antonio, TX, USA
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Amen TB, Chatterjee A, Rudisill SS, Joseph GP, Nwachukwu BU, Ode GE, Williams RJ. National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States. Orthop J Sports Med 2023; 11:23259671231187447. [PMID: 37655237 PMCID: PMC10467402 DOI: 10.1177/23259671231187447] [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: 03/02/2023] [Accepted: 04/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. Purpose To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Study Design Descriptive epidemiology study. Methods The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. Results During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Conclusion Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.
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Affiliation(s)
- Troy B. Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Abhinaba Chatterjee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Samuel S. Rudisill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriel P. Joseph
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Benedict U. Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Gabriella E. Ode
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
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Owusu-Akyaw K. The Forward Movement: Color Blind, or Blind to the Truth? Clin Orthop Relat Res 2023; 481:859-860. [PMID: 36999942 PMCID: PMC10097579 DOI: 10.1097/corr.0000000000002641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 04/01/2023]
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18
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Best MJ, Fedorka CJ, Belniak RM, Haas DA, Zhang X, Armstrong AD, Abboud JA, Jawa A, O'Donnell EA, Simon JE, Wagner ER, Malik M, Gottschalk MB, Khan AZ, Updegrove GF, Makhni EC, Warner JJP, Srikumaran U. The impact of the COVID-19 pandemic on racial disparities in patients undergoing total shoulder arthroplasty in the United States. JSES Int 2023; 7:252-256. [PMID: 36405932 PMCID: PMC9651989 DOI: 10.1016/j.jseint.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the United States and to determine whether these disparities were affected by the COVID-19 pandemic. Methods Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April to December from 2019 to 2020. Utilization was assessed for White, Black, Hispanic, and Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age, sex, CMS-hierarchical condition categories (HCC) score, dual enrollment (proxy for socioeconomic status), time-fixed effects, and core-based statistical area fixed effects was used to study difference across groups. Results In 2019, the TSA volume per 1000 beneficiaries was 1.51 for White and 0.57 for non-White, with a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P < .01). There was an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference; 8.7%, P = .02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%, P = .05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. Conclusions During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA, while disparities were less apparent for proximal humerus fracture.
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Affiliation(s)
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Robert M Belniak
- Department of Orthopaedic Surgery and Sports Medicine, Starling Physicians Group, New Britain, CT, USA
| | | | | | - April D Armstrong
- Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joseph A Abboud
- Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA.,Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Evan A O'Donnell
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston Shoulder Institute, Boston, MA, USA
| | - Jason E Simon
- Department of Orthopaedic Surgery, Harvard Medical School, Newton-Wellesley Hospital, Boston, MA, USA
| | - Eric R Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | | | - Adam Z Khan
- Northwest Permanente Physicians and Surgeons, Clackamas, OR, USA
| | - Gary F Updegrove
- Department of Orthopaedics and Rehabilitation, Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eric C Makhni
- Department of Orthopaedic Surgery, Sports Medicine, Henry Ford Health, Detroit, MI, USA
| | - Jon J P Warner
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston Shoulder Institute, Boston, MA, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Parola R, Neal WH, Konda SR, Ganta A, Egol KA. No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used. Clin Orthop Relat Res 2023; 481:324-335. [PMID: 35238810 PMCID: PMC9831154 DOI: 10.1097/corr.0000000000002142] [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: 08/10/2021] [Accepted: 01/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | | | - Sanjit R. Konda
- NYU Langone Health, New York, NY, USA
- Jamaica Hospital Medical Center, New York, NY, USA
| | - Abhishek Ganta
- NYU Langone Health, New York, NY, USA
- Jamaica Hospital Medical Center, New York, NY, USA
| | - Kenneth A. Egol
- NYU Langone Health, New York, NY, USA
- Jamaica Hospital Medical Center, New York, NY, USA
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20
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Patient Disparities and Provider Diversity in Orthopaedic Surgery: A Complex Relationship. J Am Acad Orthop Surg 2023; 31:132-139. [PMID: 36563332 DOI: 10.5435/jaaos-d-22-00410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Disparities in the access to, utilization of, and outcomes after orthopaedic surgery are a notable problem in the field that limits patients' ability to access the highest level of care and achieve optimal outcomes. Disparities exist based on numerous sociodemographic factors, with sex and race/ethnicity being two of the most well-studied factors linked to disparities in orthopaedic care. These disparities cross all subspecialties and tend to negatively affect women and racial/ethnic minorities. The increased recognition of the disparities in orthopaedic care has been paralleled by an increased recognition of the lack of diversity among orthopaedic surgeons. Although efforts are being made to improve the representation of women and underrepresented minorities among orthopaedic surgeons, the numbers, particularly of racial and ethnic minorities, show little improvement. The lack of gender and racial diversity among orthopaedic surgeons may be one of many factors related to the gender and racial disparities seen in orthopaedic care. Patients may prefer a provider that they can better identify with and that may affect care. Orthopaedic surgery as a specialty must continue to work to foster an inclusive environment and make concerted efforts to improve diversity through the recruitment of women and underrepresented minorities, among others, for the benefit of patients, surgeons, and the continued growth of the field as a whole.
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21
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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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Gitajn IL, Werth P, Fernandes E, Sprague S, O'Hara NN, Bzovsky S, Marchand LS, Patterson JT, Lee C, Slobogean GP. Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race. JAMA Netw Open 2022; 5:e2244357. [PMID: 36449289 PMCID: PMC9713603 DOI: 10.1001/jamanetworkopen.2022.44357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Racial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations. OBJECTIVE To assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022. EXPOSURES Patient-level and hospital-level race, ethnicity, and insurance status. MAIN OUTCOMES AND MEASURES Primary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level. RESULTS A total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79). CONCLUSIONS AND RELEVANCE In this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.
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Affiliation(s)
| | - Paul Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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23
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Rudisill SS, Rahman R, Lane J, Amen TB. Letter to the Editor: No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways are Used. Clin Orthop Relat Res 2022; 480:1623-1624. [PMID: 35728066 PMCID: PMC9278904 DOI: 10.1097/corr.0000000000002272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | - Rafa Rahman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Lane
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Troy B. Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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