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Xu AL, Humbyrd CJ, De Mattos CBR, LaPorte D. The Importance of Perceived Barriers to Women Entering and Advancing in Orthopaedic Surgery in the US and Beyond. World J Surg 2023; 47:3051-3059. [PMID: 37735223 DOI: 10.1007/s00268-023-07165-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Global perceptions of barriers to women in orthopaedics have not been assessed. The purpose of this study was to determine the importance of international barriers to women entering and advancing within orthopaedic surgery. METHODS An anonymous, online survey was distributed to women medical students, trainees, and practicing surgeons via Women in Orthopaedics Worldwide, the "Women in Ortho" Facebook page, and individual programmes. Participants were asked to rate perceived barriers to (1) pursuing training and (2) career advancement on a scale of 1-5, with 5 being the most important and relative to other barriers. Descriptive statistics and univariate analyses were employed. RESULTS The survey yielded 237 US (84.0%) and 45 international (16.0%) respondents. Per entering orthopaedic surgery, the most important barriers were male-dominated culture, lack of a strong women mentor, and lack of female representation at home institution. Compared with the US surgeons/trainees, international respondents cited greater societal disapproval (2.8 ± 1.2 vs. 3.4 ± 1.3, P = 0.01). Medical students assigned less importance to lack of exposure, more to lack of resources for creating competitive applications (P < 0.05). Regarding career advancement, lack of women leadership, family responsibilities, and gender-biased selection for promotion were the most important. International surgeons/trainees noted greater concern for societal disapproval (3.5 ± 1.5 vs. 2.6 ± 1.3, P = 0.003) and were more likely to rank sexual harassment in their top three (17.6 vs. 4.2%, P = 0.02). CONCLUSION While notable differences exist, there is striking similarity across countries and position levels in perceived barriers to women entering and advancing in orthopaedic surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amy L Xu
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Casey J Humbyrd
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Dawn LaPorte
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA
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Rahman R, Xu AL, Dhanjani SA, Zhang B, Nayar SK, Humbyrd CJ, LaPorte D. Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage? Hand (N Y) 2022; 17:95S-102S. [PMID: 35189731 PMCID: PMC9793622 DOI: 10.1177/15589447221075669] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs. METHODS We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05. RESULTS There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage. CONCLUSIONS Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rafa Rahman
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Amy L. Xu
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Bo Zhang
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Suresh K. Nayar
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Dawn LaPorte
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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Baxter JR, Hullfish TJ, Farber DC, Humbyrd CJ. Achilles Tendon Loading During Walking Differs Between Commonly Used Immobilizing Boots. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s00576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Category: Sports; Basic Sciences/Biologics Introduction/Purpose: Achilles tendon ruptures have increased 10-fold in the past three decades, leading to long-term functional deficits in nearly two-thirds of patients. To counter this, rehabilitation protocols have been developed to strike a balance between protecting the healing tendon from re-rupture while allowing patients to return to activities of daily living as early as possible. However, Achilles tendon loading is neither prescribed nor quantified during immobilization and there is no standardized method of immobilization. Therefore, the purpose of this study was to quantify the amount of tendon loading experienced while walking in 3 different kinds immobilizing boot with respect to prescribed ankle angle and walking speed. Methods: Two healthy-young adults (2M; Age: 29.6 +- 2.3 y/o; BMI: 30 +- 7) walked over flat ground while wearing 3 different immobilizing boots and athletic shoes after providing written informed consent in this IRB approved study. We calculated Achilles tendon loading while subjects walked in 3 boots that positioned the ankle in 30 degrees of plantar flexion (Figure A, Air Cam Walker, United Ortho; AirSelect Walker, Aircast, VACOped, OPED). In all three boots, an instrumented insole (Loadsol, Novel) was placed under the foot to quantify load experienced by the tendon. We calculated the Achilles tendon loading profiles during gait for each immobilizing boot and compared them against the normal shod condition. We also provided the surgical repair threshold of 0.5 bodyweights to visualize the potential efficacy of each immobilizing boot for early rehabilitation when the tendon is early in the healing phase. Results: As expected, tendon loading was highest in the shod condition with no ankle bracing and lowest in the fully plantarflexed adjustable boot (Figure B). On average, the immobilizing boots reduced tendon loading decreased by 68% compared to unsupported walking in shoes but there were differences among the boots. The 3 different immobilizing boots provided differing levels of support. The 2 walking boots that use heel wedges to support the ankle in plantar flexion provided the least support, reducing loading by an average of 60-68%. The more rigid boot that constrained ankle angle using a posterior strut reduced tendon loading by 77% compared to gait in a normal walking shoe. Based on biomechanical studies of Achilles tendon repair strength in cadaveric experiments, only the rigid boot with the posterior strut reduced tendon loading biomechanics to levels that could be resisted by the surgical repair (Figure B). Conclusion: In this study, we used an instrumented insole to quantify Achilles tendon loading in a variety of immobilizing boots used by rupture patients. Our initial findings show that tendon loading is varies greatly between boot types and patients, highlighting the importance of understanding how these loads change in patients. Our future work centers around identifying the tendon loading profiles that promote tendon healing and optimize patient outcomes. These loading profiles will then provide the quantitative data needed to personalize loading for patients and guide rehabilitation to improve outcomes.
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Xu AL, Dunham AM, Enumah ZO, Humbyrd CJ. Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study. J Orthop Surg Res 2021; 16:736. [PMID: 34952626 PMCID: PMC8709537 DOI: 10.1186/s13018-021-02881-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding. METHODS One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05. RESULTS Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9-31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006-0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09-0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7-46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0-7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07-0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5-9.8, p = 0.005). CONCLUSIONS Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history.
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Affiliation(s)
- Amy L Xu
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexandra M Dunham
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Zachary O Enumah
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Casey J Humbyrd
- Department of Orthopaedic Surgery, The University of Pennsylvania, 230 West Washington Square, 5th Floor Farm Journal Building,, Philadelphia, PA, 19106, USA.
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Mawn JG, Rao SS, Chaudhry YP, Gottlich C, Lobaton GO, Sabharwal S, Sterling RS, Humbyrd CJ. Septic Arthritis Among Users of Injection Drugs: Clinical Course and Microbial Characteristics. Orthopedics 2021; 44:e747-e752. [PMID: 34618644 DOI: 10.3928/01477447-20211001-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non-IDU-associated SA (non-IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex (P=.001), younger age (P<.001), lower body mass index (P<.001), tobacco use (P<.001), and psychiatric diagnosis (P=.04) and was more likely to involve methicillin-resistant Staphylococcus aureus (P<.001). The IDU-SA was associated with discharge to a skilled nursing facility or against medical advice (P<.001) and with loss to follow-up (P=.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non-IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non-IDU-SA. [Orthopedics. 2021;44(6):e747-e752.].
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Rahman R, Canner JK, Haut ER, Humbyrd CJ. Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients? Clin Orthop Relat Res 2021; 479:575-585. [PMID: 32947286 PMCID: PMC7899604 DOI: 10.1097/corr.0000000000001493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use. QUESTIONS/PURPOSES (1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA? METHODS In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05. RESULTS THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325). CONCLUSION Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Rafa Rahman
- R. Rahman, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- J. K. Canner, Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Division of Acute Care Surgery, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Anesthesiology and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Emergency Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, The Armstrong Institute for Patient Safety and Quality, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- C. J. Humbyrd, Department of Orthopaedic Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- R. Rahman, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- J. K. Canner, Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Division of Acute Care Surgery, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Anesthesiology and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Emergency Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, The Armstrong Institute for Patient Safety and Quality, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- C. J. Humbyrd, Department of Orthopaedic Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliott R Haut
- R. Rahman, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- J. K. Canner, Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Division of Acute Care Surgery, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Anesthesiology and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Emergency Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, The Armstrong Institute for Patient Safety and Quality, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- C. J. Humbyrd, Department of Orthopaedic Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey J Humbyrd
- R. Rahman, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- J. K. Canner, Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Division of Acute Care Surgery, Department of Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Anesthesiology and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Emergency Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, The Armstrong Institute for Patient Safety and Quality, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
- E. R. Haut, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- C. J. Humbyrd, Department of Orthopaedic Surgery, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
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