Racial Disparities in Total Joint Arthroplasty

The Utility of Neighborhood Social Vulnerability Indices in Predicting Non-Home Discharge Disposition Following Revision Total Joint Arthroplasty: A Comparison Study

BACKGROUND

Identifying risk factors associated with non-home discharge (NHD) following revision hip and knee total joint arthroplasty (TJA) could reduce the rate of preventable discharge to rehabilitation or skilled nursing facilities. Neighborhood-level deprivation indices are becoming an increasingly important measure of socioeconomic disadvantage as these indices consider multiple social determinants of health. This study aimed to compare the utility of widely used neighborhood social vulnerability indices in predicting NHD following revision TJA patients.

METHODS

This study included 1,043 consecutive patients who underwent revision TJA at a single tertiary health system. There were three multivariate logistic regression analyses with the outcome of NHD performed using the area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index while controlling for other demographic variables. Neighborhood-level indices were included in the analysis as continuous variables and categorical quartiles, with the lowest quartile representing the least deprived neighborhoods of the patient cohort. The strength of the association of significant indices was measured.

RESULTS

Patients in the highest ADI and SDI quartiles demonstrated higher odds of NHD compared to the cohort with the lowest quartile (ADI OR [odds ratio] = 1.93, 95% CI [confidence interval] = 1.23 to 3.03, P = 0.005; SDI OR = 1.86, 95% CI = 1.18 to 2.91, P = 0.007). Discharge disposition was more strongly associated with ADI than SDI (0.68 versus 0.26). Age, American Society of Anesthesiologist status, and alcohol use were independent determinants of discharge disposition. No significant association was seen between social vulnerability index and discharge disposition.

CONCLUSIONS

Area-level indices can be utilized to identify patients at higher risk of NHD following revision TJA. This study highlights the important differences between these indices' utility when evaluating their effects on clinical outcomes in this patient population. The findings shed light on the potential of integrating these tools into policy development, clinical preoperative programs, and research to better understand and address the health disparities in arthroplasty outcomes.

Racial and Ethnic Disparities in Predictive Accuracy of Machine Learning Algorithms Developed Using a National Database for 30-Day Complications Following Total Joint Arthroplasty

BACKGROUND

While predictive capabilities of machine learning (ML) algorithms for hip and knee total joint arthroplasty (TJA) have been demonstrated in previous studies, their performance in racial and ethnic minority patients has not been investigated. This study aimed to assess the performance of ML algorithms in predicting 30-days complications following TJA in racial and ethnic minority patients.

METHODS

A total of 267,194 patients undergoing primary TJA between 2013 and 2020 were identified from a national outcomes database. The patient cohort was stratified according to race, with further substratification into Hispanic or non-Hispanic ethnicity. There were two ML algorithms, histogram-based gradient boosting (HGB), and random forest (RF), that were modeled to predict 30-days complications following primary TJA in the overall population. They were subsequently assessed in each racial and ethnic subcohort using discrimination, calibration, accuracy, and potential clinical usefulness.

RESULTS

Both models achieved excellent (Area under the curve (AUC) > 0.8) discrimination (AUCHGB = AUCRF = 0.86), calibration, and accuracy (HGB: slope = 1.00, intercept = -0.03, Brier score = 0.12; RF: slope = 0.97, intercept = 0.02, Brier score = 0.12) in the non-Hispanic White population (N = 224,073). Discrimination decreased in the White Hispanic (N = 10,429; AUC = 0.75 to 0.76), Black (N = 25,116; AUC = 0.77), Black Hispanic (N = 240; AUC = 0.78), Asian non-Hispanic (N = 4,809; AUC = 0.78 to 0.79), and overall (N = 267,194; AUC = 0.75 to 0.76) cohorts, but remained well-calibrated. We noted the poorest model discrimination (N = 1,870; AUC = 0.67 to 0.68) and calibration in the American-Indian cohort.

CONCLUSIONS

The ML algorithms demonstrate an inferior predictive ability for 30-days complications following primary TJA in racial and ethnic minorities when trained on existing healthcare big data. This may be attributed to the disproportionate underrepresentation of minority groups within these databases, as demonstrated by the smaller sample sizes available to train the ML models. The ML models developed using smaller datasets (e.g., in racial and ethnic minorities) may not be as accurate as larger datasets, highlighting the need for equity-conscious model development.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Outpatient Versus Inpatient Total Hip and Knee Arthroplasty in Morbidly Obese Patients

BACKGROUND

Morbidly obese patients undergoing total joint arthroplasty (TJA) face increased postoperative complications, yet studies assessing the safety of this surgery in the outpatient setting for this population are lacking. This study aimed to fill this gap by assessing the safety and benefits of outpatient TJA in morbidly obese patients.

METHODS

This study is a retrospective review of a commercial claims database. Based on the setting of the procedure, the patients were divided into four groups as follows: inpatient-TKA (total knee arthroplasty), outpatient-TKA, inpatient-THA (total hip arthroplasty), and outpatient-THA. The two TKA groups were matched based on age, sex, and the Charlson Comorbidity Index. The THA groups were matched similarly. The 30- and 90-day medical and surgical complications were compared between these groups. There were 5,500 patients included in each of the outpatient and inpatient TKA groups and 1,550 in each of the outpatient and inpatient THA groups.

RESULTS

Patients undergoing inpatient TKA had higher rates of pulmonary embolism, urinary tract infection, transfusions, intensive care unit admissions, emergency department visits, readmissions at 30 days, surgical site infections, periprosthetic joint infection, prosthetic dislocations, and costs. As for the inpatient THA group, they had higher rates of pulmonary embolism, urinary tract infection, transfusions, intensive care unit admissions, emergency department visits, and costs.

CONCLUSIONS

It is well-established that morbidly obese patients undergoing TJA have higher complication rates than normal-weight patients, and patients should be counseled before arthroplasty. This study highlights the safety and benefits of outpatient TJA in morbidly obese patients. However, one should note that this was done using an insurance database, in which results may differ if it was done in a public and lower socioeconomic setting. Therefore, future prospective studies are needed to confirm the findings before implementing outpatient TJA in morbidly obese patients.

Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations: a matched cohort analysis of primary shoulder arthroplasties

Background

Within orthopedic surgery, there remain limited data evaluating the impact of racial and socioeconomic disparities on outcomes of primary shoulder arthroplasty (SA) over time. As such, we analyzed both short- and longer-term outcome differences in complications, reoperations, and revision surgery of primary SA when performed in non-White patients when compared to a matched cohort of White patients who had undergone SA.

Methods

Over a 39-year period (1981-2020), an institutional Total Joint Registry Database was utilized to identify all non-White patients (Asian/Pacific Islander, Black, Hispanic or Latino, American Indian/Alaska Native, other) who underwent primary SA with a minimum of 2 years of follow-up. The search identified 275 primary SA (46 hemiarthroplasties, 97 anatomic total shoulder arthroplasties, and 132 reverse total shoulder arthroplasties). The ethnicity composition was 8.7% Asian, 27.3% Black, 37.8% Hispanic, 12.4% American Indian, and 13.8% other. This cohort was matched 1:2 according to age, sex, diagnosis, implant, and surgical year to a control group of 550 White patients who had undergone SA. The rates of medical and surgical complications, reoperations, revisions, and implant survivorship were assessed. The mean follow-up time was 6.3 years (range, 2 to 40 years).

Results

Comparisons between the non-White and White matched cohorts demonstrated a higher rate of tobacco use (14.2% vs. 10.5%; P < .001), diabetes (21.5% vs. 11.8%; P < .001), length of stay (1.9 vs. 1.6 days; P = .014), and a lower rate of private commercial insurance (27.3% vs. 44.5%; P < .001 in the non-White cohort. Within the first 90 days after surgery, non-White patients had a higher rate of emergency department visits (5.5% vs. 0.9%; P < .001) and unplanned readmissions (2.9% vs. 0.7%; P = .014). After the first 90 postoperative days, there were no differences regarding medical (1.8% vs. 0.7%; P = .135) or surgical complications (12.0% vs. 13.6%; P = .446). Ten-year survivorship free of all-cause complication (76.8% vs. 81.5%; P = .370), reoperation (84.9% vs. 89.8%; P = .492), and revision (89.3% vs. 91.4%; P = .715) were similar between the non-White and White cohorts.

Discussion

After accounting for age, sex, and surgical indication, patient race and ethnicity were not associated with an increased risk of long-term all-cause complications, reoperations, or revision surgery after primary SA. However, within the first 90 postoperative days, non-White patients had a higher likelihood of unplanned emergency room visits and readmissions.

Health Disparities in Aseptic Revision Total Hip Arthroplasty: Assessing the Impact of Social Determinants of Health

BACKGROUND

Social determinants of health (SDOH) have been shown to reliably predict outcomes in patients undergoing orthopaedic procedures. However, there remains a paucity of data in the literature on whether SDOH can predict adverse outcomes in those undergoing aseptic revision total hip arthroplasty (rTHA). We aimed to examine the relationship between SDOH and clinical outcomes in aseptic rTHA.

METHODS

This retrospective study identified 843 patients undergoing aseptic rTHA using an institutional joint registry. Data on demographics, length of stay, 90-day complications, discharge disposition, and re-revisions were recorded. The Area Deprivation Index (ADI) and four subscales of the Social Vulnerability Index (SVI) were identified using census tract codes. High vulnerability to SDOH was defined as the top quartile for ADI and each SVI category. A multivariate regression was performed to identify risk factors for worse clinical outcomes.

RESULTS

Patients who had a higher ADI (43.2 versus 22.6%, P < 0.001) and SVI (32.9 versus 22.9%, P = 0.011) were revised for aseptic loosening at a higher proportion compared to their counterparts. Additionally, a lower prevalence of osteolysis was observed in patients who had a high ADI compared to those who had a low ADI (3.7 versus 10.6%, P = 0.048). In multivariate analyses, a high overall SVI was an independent risk factor for mortality (odds ratio [OR] = 2.40, P = 0.020). A higher household SVI was associated with increased mortality (OR = 2.13, P = 0.038) and reoperations (OR = 1.89, P = 0.039). Similarly, patients who had high housing and transportation SVI had higher odds of 90-day complications (OR = 1.66, P = 0.045) and PJI episodes (OR = 2.33, P = 0.028).

CONCLUSIONS

Patients who had higher levels of deprivation exhibited different surgical indications and poorer clinical outcomes following aseptic rTHA. Our findings suggest that SVI is an effective tool for assessing SDOH.

Two Decades Since the Unequal Treatment Report: The State of Racial, Ethnic, and Socioeconomic Disparities in Elective Total Hip and Knee Replacement Use

ABSTRACT

Published in 2003 by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care placed an unprecedented spotlight on disparities in the U.S. health-care system. In the 2 decades since the publication of that landmark report, disparities continue to be prevalent and remain an important significant national concern. This article synthesizes the evolution, current state, and future of racial and ethnic disparities in the use of elective total joint replacement surgeries. We contextualize our impressions with respect to the recommendations of the Unequal Treatment Report.

Body Mass Index Improvement Reduces Total Knee Arthroplasty Complications Among Patients Who Have Extreme, but Not Severe, Obesity

BACKGROUND

While morbid obesity has been associated with increased complication risk in primary total knee arthroplasty (TKA), limited evidence is available to attribute decreased surgical complication rates with body mass index (BMI) reduction.

METHODS

We retrospectively assessed 464 unilateral TKAs performed in morbidly obese patients, including 158 extremely obese (BMI ≥ 45) and 306 severely obese patients (BMI 40 to 44.9). A detailed medical record review identified concurrent modifiable risk factors and successful preoperative BMI reduction, reaching either a contemporary risk target (BMI < 40) or an institutionally accepted threshold (BMI < 45). Postoperative blood glucose levels and 1-year adverse outcomes (periprosthetic joint infection, wound dehiscence, knee manipulation, periprosthetic fracture) were compared to 557 contemporary control subjects with expected slightly lower (moderate obesity, BMI 35 to 39.9) or sufficiently lower complication risk (overweight, BMI 25 to 29.9).

RESULTS

Periprosthetic joint infection and postoperative hyperglycemia were identified more frequently among morbidly obese patients in comparison with a moderately obese control group. Extremely obese patients (BMI ≥ 45) whose BMI improved below 45 had no measurable difference in infection risk from the control group (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.04 to 16.88), while those with a nonimproved BMI had a significantly higher risk (OR 7.70, 95% CI 1.89 to 31.41). No significant differences in the risk for infection were observed between severely obese patients (BMI 40 to 44.9) with preoperative BMI improvement (1.5% rate, OR 1.70, 95% CI 0.17 to 16.57) or nonimprovement (1.7% rate, OR 1.87, 95% CI 0.41 to 8.43).

CONCLUSIONS

Preoperative medical optimization may decrease postoperative TKA complications. The findings of this study support BMI improvement for extremely obese patients (BMI ≥ 45). The assignment of 40 BMI as a threshold for otherwise healthy patients may exclude patients from potential surgical benefits without realizing risk reduction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

The impact of a patient advisory board on a clinical comparative effectiveness trial: a comparison of patient and researcher perspectives

Aim: To examine contributions of a patient advisory board (PAB) to the design and conduct of The Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) Trial (NCT02810704) and compare perceptions of PAB members and researchers on the Trial. Materials & methods This evaluation of the PAB was conducted by Clinical Coordinating Center (CCC) members who first discussed PAB contributions, leading to the design of a semi-structured WebEx interview individually querying PAB members on their experience. Two study team members analyzed transcriptions of the interviews for common themes, which were discussed and affirmed at an in-person meeting with PAB members. Results: The contribution most frequently cited as meaningful by PAB members was the creation of a recruitment video. In contrast, the research team considered the most impactful PAB recommendation to be omission of pneumatic compression boots as a study variable. PAB members spoke highly of their involvement in the trial and emphasized shared decision-making in the patient-physician relationship. Conclusion: Researchers and PAB members had different opinions about which PAB contributions were most impactful to the study. This likely derives from differences in perspective; PAB members focused on patient experience and the patient-surgeon relationship while researchers focused primarily on trial outcomes. PAB contributions led to two major protocol changes that had a substantial positive effect on trial design, recruitment and enrollment. This evaluation adds to the engagement literature, which contains little on what patients think of their involvement in the design and conduct of clinical research studies and will aid in encouraging treatment preference discussions between patient and surgeon, thereby supporting the goal of improved patient outcomes.

The Effect of Social Drivers of Health on 90-Day Readmission Rates and Costs After Primary Total Hip and Total Knee Arthroplasty

INTRODUCTION

The effect of social drivers of health (SDOH) on readmissions and costs after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is poorly understood. Policies such as the Hospital Readmissions Reduction Program have targeted overall readmission reduction, using value-based strategies to improve healthcare quality. However, the implications of SDOH on these outcomes are not yet understood. We hypothesized that the area deprivation index (ADI) as a surrogate for SDOH would markedly influence readmission rates and healthcare costs in the 90-day postprocedural period for THA and TKA.

METHODS

We used the 100% US fee-for-service Medicare claims data from 2019 to 2021. Patients were identified using diagnosis-related groups. Our primary outcomes included 90-day unplanned readmission after hospital discharge and cost of care, treated as "high cost" if > 1 standard deviation above the mean. The relationships between ADI and primary outcomes were estimated with logistic regression models.

RESULTS

A total of 628,399 patients were included in this study. The mean age of patients was 75.6, 64% were female, and 7.8% were dually eligible for Medicaid. After full covariate adjustment, readmission was higher for patients in more deprived areas (high Area Deprivation Index (ADI)) (low socioeconomic status (SES) group OR: 1.30 [95% confidence intervals 1.23, 1.38]). ADI was associated with high cost before adjustment (low SES group odds ratio 1.08 [95% confidence intervals 1.04, 1.11], P < 0.001), although, after adjustment, this association was lost.

DISCUSSION

This analysis highlights the effect of SDOH on readmission rates after THA and TKA. A nuanced understanding of neighborhood-level disparities may facilitate targeted strategies to reduce avoidable readmissions in orthopaedic surgery. Regarding cost, although there is some association between ADI and cost, this study may illustrate that ADI for THA and TKA is not sufficiently granular to identify the contribution of social drivers to elevated costs.

Preoperatively predicting failure to achieve the minimum clinically important difference and the substantial clinical benefit in patient-reported outcome measures for total hip arthroplasty patients using machine learning

BACKGROUND

Attention to the collection of patient-reported outcomes measures (PROMs) associated with total hip arthroplasty (THA) is growing. The aim of this study was to preoperatively predict failure to achieve the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) between pre- and postoperative PROMs. In addition, we sought to identify factors predictive of failure to achieve MCID and SCB in patients undergoing a THA.

METHODS

A retrospective query of the electronic health record data was performed at a single institution. Outcomes of interest were the anchor-based MCID, the distribution-based MCID, and the SCB for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement. Several machine learning models were built for each outcome and were evaluated by areas under the receiver operating characteristic curve and the precision-recall curve. Furthermore, logistic regression models were used to identify significant risk factors.

RESULTS

Of the 857 patients who underwent THA, 350 patients completed both pre- and postoperative surveys. Of the final sample (i.e., 350 patients), 56 (16.0%), 29 (8.3%), and 71 (20.3%) failed to reach the anchor-based (i.e., 17.7 points) and distribution-based (10.6 points) MCIDs and the SCB (i.e., 22.0 points). The machine learning model performances were far beyond the baseline and comparable to the ones in existing studies, suggesting reliability in the prediction. Two shared factors associated with the failure in both the MCIDs and the SCB were highlighted: a patient's race and pre-existing mental illness.

CONCLUSION

Understanding the risk factors of failing to meet MCID and SCB may provide a more objective opportunity to quantify patient and surgeon expectations associated with THA. Our findings call stakeholders' particular attention to patients with preoperative mental disorders, and raise further questions regarding the impact of race, in the care of patients with degenerative hip disease.

Telemedicine Use Following Onset of the COVID-19 Pandemic Was Associated With Youth and White Race but Not With Socioeconomic Deprivation: A Retrospective Cohort Study of Orthopedic Patients

Background

The use of telemedicine increased greatly following the onset of the COVID-19 pandemic. It is unclear whether and how sociodemographic factors have affected orthopedics patients' use of this technology in the pandemic.

Purpose

The aim of this study was to determine how patient demographic variability in telemedicine use is influenced by the Area Deprivation Index (ADI) and distance to clinical site among patients seeking care for hip and knee arthritis from orthopedic surgeons.

Methods

Demographic data and visit type were collected from the electronic medical record for patients seen in our academic medical center either before or during the COVID-19 pandemic by orthopedic surgeons who specialize in hip and knee arthroplasty. Univariate and multivariate analyses were performed regarding age, race, insurance status, ADI, and distance to a clinical site.

Results

In the COVID era, among 4901 visits with 3124 unique patients, those using telemedicine were younger and more likely to be White compared to those who did not use telemedicine. There was no significant difference in telemedicine use based on ADI, distance to a clinical site, or insurance status.

Conclusions

This retrospective analysis suggests that orthopedic patients who were White and of younger age were more likely to use telemedicine in the first year of the COVID-19 pandemic. There was no statistically significant relationship between distance from a clinical site or ADI and telemedicine use, suggesting that factors other than these are greater contributors to telemedicine utilization in our cohort. Further information is needed to determine how telemedicine may disproportionately limit access to orthopedic care according to these and other patient factors.

Early Clinical Outcomes of "Lemon-Dropped" Complex Primary Total Joint Arthroplasty Patients to a Tertiary Care Center

BACKGROUND

In the era of value-based care, pressures lead to cherry-picking healthier patients and lemon-dropping riskier patients to higher levels-of-care. This study examined whether "lemon-dropped" primary total joint arthroplasty (pTJA) patients require increased health care resources and experience worse outcomes.

METHODS

This was a retrospective cohort study of all pTJAs at one tertiary care center in 2022, excluding bilaterals, acute fractures, oncologic cases, and conversion hips. Patients were classified via referral pattern as simple or complex (referred for medical or surgical complexity). Primary outcomes were implant costs and any emergency department visit, readmission, reoperation, or complication within 90 days. Secondary outcomes were distance traveled to the hospital, anesthesia type, estimated blood loss, case duration, time in the recovery unit, length of stay, and discharge disposition. Outcomes were assessed via electronic medical record review and analyzed via Fisher's exact and unpaired Welch's t-tests.

RESULTS

In total 641 pTJAs (322 hips, 319 knees) met inclusion criteria; 10.3% were complex referrals. Complex patients were younger (59 versus 66 years, P < .05) and more often non-White (41 versus 31%, P < .001), non-English speaking (11 versus 7%, P < .001), and had nonprimary osteoarthritis as a surgical indication (59 versus 12%, P < .001), but had similar Charlson Comorbidity Index and American Society of Anesthesiologists scores. Complex patients had increased odds of 90-day emergency department visits (OR [odds ratio] = 2.11, P = .04), 90-day complications (OR = 2.63, P < .001), and non-home discharge (OR = 2.60, P = .006); higher mean relative implant costs (1.31x, P < .001); longer time in the operating room (181 versus 158 minutes P < .001), time in surgery (125 versus 105 minutes, P < .001), and length of stay (3.2 versus 1.7 days, P = .005).

CONCLUSIONS

"Lemon-dropped" pTJAs had worse early clinical outcomes and higher health care utilization, despite a control group with patients ill enough to utilize a tertiary care center as their medical home. Reimbursement models and evaluation metrics must account for these differences.

Post-Acute Care Trends and Disparities After Joint Replacements in the United States, 1991-2018: A Systematic Review

OBJECTIVE

To review evidence on post-acute care (PAC) use and disparities related to race and ethnicity and rurality in the United States over the past 2 decades among individuals who underwent major joint replacement (MJR).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

We included studies that examined US PAC trends and racial and ethnic and/or urban vs rural differences among individuals who are aged ≥18 years with hospitalization after MJR.

METHODS

We searched large academic databases (PubMed, CINAHL, Embase, Web of Science, and Scopus) for peer-reviewed, English language articles from January 1, 2000, and January 26, 2022.

RESULTS

Seventeen studies were reviewed. Studies (n = 16) consistently demonstrated that discharges post-MJR to skilled nursing facilities (SNFs) or nursing homes (NHs) decreased over time, whereas evidence on discharges to inpatient rehab facilities (IRFs), home health care (HHC), and home without HHC services were mixed. Most studies (n = 12) found that racial and ethnic minority individuals, especially Black individuals, were more frequently discharged to PAC institutions than white individuals. Demographic factors (ie, age, sex, comorbidities) and marital status were not only independently associated with discharges to institutional PAC, but also among racial and ethnic minority individuals. Only one study found urban-rural differences in PAC use, indicating that urban-dwelling individuals were more often discharged to both SNF/NH and HHC than their rural counterparts.

CONCLUSIONS AND IMPLICATIONS

Despite declines in institutional PAC use post-MJR over time, racial and minority individuals continue to experience higher rates of institutional PAC discharges compared with white individuals. To address these disparities, policymakers should consider measures that target multimorbidity and the lack of social and structural support among socially vulnerable individuals. Policymakers should also consider initiatives that address the economic and structural barriers experienced in rural areas by expanding access to telehealth and through improved care coordination.

Optimizing Total Hip and Knee Arthroplasty Among an Underserved Population: Lessons Learned From a Quality-Improvement Initiative

Background

Under-represented minorities and those with noncommercial insurance have higher medical comorbidities and complications following elective total joint arthroplasty (TJA). In an effort to bridge this gap, our center implemented a preoperative optimization protocol for TJA in a Medicaid Clinic (Clinic). The purpose of this study is to assess the effectiveness of that protocol and highlight challenges associated with caring for this patient population.

Methods

This retrospective analysis included 117 patients undergoing TJA between January 2015 and January 2020. In 2015, the protocol was implemented as a mandatory practice prior to TJA. A contemporary control cohort from the private office was also analyzed. Patient demographics, American Society of Anesthesiologists score, and postoperative complications were collected.

Results

Within the clinic group, 52.5% (62) patients identified as Hispanic with 46.6% (55) Spanish-speaking as primary language, compared to 9.3% (11) and 8.5% (10) in the office group (P = .0001), respectively. Clinic group patients were significantly more likely to experience a complication compared to office patients (20 vs 7, respectively). There was no difference in complication or reoperation rate between clinic patients who underwent the optimization protocol and those who did not.

Conclusions

The findings from this study highlight the demographic and comorbidities profile of an underserved population, and report on results of a quality improvement initiative among that population, which failed to improve postoperative outcomes. These results underscore the need for further study in this population to improve outcomes and health equity.

Racial disparity in postoperative complications following shoulder arthroplasty (SA): A systematic review and meta-analysis

Introduction

There has been an emphasis on racial disparities in orthopedic surgery. Recently, literature suggested Black and Hispanic patients at increased risk for adverse outcomes after Shoulder Arthroplasty (SA), but data regarding it is sparse and inconclusive. Therefore, we aim to conduct a meta-analysis to assess the role of racial disparity in causing adverse outcomes after SA.

Methods

Following PRISMA guidelines, electronic databases PubMed, Scopus, Cochrane, and Google Scholar were queried. Studies meeting inclusion criteria were included. Results were analyzed by pooling Odds ratios along 95% Confidence interval, using random-effects model on RevMan 5.3.

Results

A total of 14 selected studies evaluated 1,781,783 patients. We found Black patients at higher risk of post-SA complications than White patients (OR 1.32(95% CI 1.25-1.39; p < 0.00001; I2 = 0%). No significant risk in Hispanics compared to white patients (OR 0.94(95% CI 0.81-1.09); p = 0.41; I2 = 65%). Compared to whites, black patients were at higher risk of an extended length of stay, postoperative blood transfusion, sepsis, venous thromboembolism, and non-home discharge. Compared to white patients, Hispanics were at higher risk for postoperative blood transfusion. Whites showed increased risk for readmission.

Conclusion

Following SA, Black patients were likely to develop complications compared to White patients but no significant risk in Hispanics compared to Whites.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BACKGROUND

African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA.

METHODS

Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant.

RESULTS

The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02).

CONCLUSIONS

The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Diversity of Backgrounds and Academic Accomplishments for Presidents Elected to Hip and Knee Arthroplasty Societies in the United States

BACKGROUND

Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons.

METHODS

This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022).

RESULTS

There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05).

CONCLUSIONS

Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty.

Rotator Cuff Repair: Racial Disparities in Operative Time and Utilization of Arthroscopic Techniques

Background Racial disparities are prevalent within the field of orthopedics and include the utilization of varying resources as well as outcomes following surgery. This study investigates racial differences between Black and White patients in the surgical treatment of rotator cuff repair (RCR) and 30-day postoperative complications following RCR. Materials and methods Data were drawn from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to create a study population consisting of Black and White patients who underwent RCR between 2015 and 2019. A bivariate analysis was conducted to compare patient demographics and comorbidities. Multivariate logistic regression, controlling for all significantly linked patient demographics and comorbidities, was performed to examine the relationships between Black race and complications. Results Our analysis included 32,073 patients, of whom 3,318 (10.3%) were Black and 28,755 (89.7%) were White. The female gender, younger age groups, greater BMI groups, ASA classification ≥3, cigarette use, and comorbid congestive heart failure (CHF), diabetes, and hypertension were all significantly associated with patients who identified as Black. We found no significant differences in 30-day postoperative complications between Black and White patients. Furthermore, Black patients were found to be independently associated with a greater likelihood of undergoing arthroscopic RCR versus open RCR, as well as experiencing a longer total operation time of ≥80 minutes. Conclusions We report no differences in 30-day postoperative complications between Black and White patients undergoing RCR between 2015 and 2019. However, Black race was independently associated with higher rates of arthroscopic RCR and longer operative times.

Racial and Ethnic Minority Patients Have Increased Complication Risks When Undergoing Surgery While Not Meeting Clinical Guidelines

BACKGROUND

Clinical guidelines for performing total joint arthroplasty (TJA) have not been uniformly adopted in practice because research has suggested that they may foster inequities in surgical access, potentially disadvantaging minority sociodemographic groups. The aim of this study was to assess whether undergoing TJA without meeting clinical guidelines affects complication risk and leads to disparities in postoperative outcomes.

METHODS

This retrospective cohort study evaluated the records of 11,611 adult patients who underwent primary TJA from January 1, 2010, to December 31, 2020, at an academic hospital network. Based on self-reported race and ethnicity, 89.5% of patients were White, 3.5% were Black, 2.9% were Hispanic, 1.3% were Asian, and 2.8% were classified as other. Patients met institutional guidelines for undergoing TJA if they had a hemoglobin A1c of <8.0% and a body mass index of <40 kg/m 2 and were not currently smoking. A logistic regression model was utilized to identify factors associated with complications, and a mixed-effects model was utilized to identify factors associated with not meeting guidelines for undergoing TJA.

RESULTS

During the study period, 11% (1,274) of the 11,611 adults who underwent primary TJA did not meet clinical guidelines. Compared with the group who met guidelines, the group who did not had higher proportions of Black patients (3.2% versus 6.0%; p < 0.001) and Hispanic patients (2.7% versus 4.6%; p < 0.001). An increased risk of not meeting guidelines at the time of surgery was demonstrated among Black patients (odds ratio [OR], 1.60 [95% confidence interval (CI), 1.22 to 2.10]; p = 0.001) and patients insured by Medicaid (OR, 1.75 [95% CI, 1.26 to 2.44]; p = 0.001) or Medicare (OR, 1.22 [95% CI, 1.06 to 1.41]; p = 0.007). Patients who did not meet guidelines had a higher risk of reoperation than those who met guidelines (7.7% [98] versus 5.9% [615]; p = 0.017), including a higher risk of infection-related reoperation (3.1% [40] versus 1.4% [147]; p < 0.001).

CONCLUSIONS

We found that patients who underwent TJA despite not meeting institutional preoperative criteria had a higher risk of postoperative complications. These patients were more likely to be from racial and ethnic minority groups, to have a lower socioeconomic status, and to have Medicare or Medicaid insurance. These findings underscore the need for surgery-related shared decision-making that is informed by evidence-based guidelines in order to reduce complication burden.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Racial and ethnic disparities in regional anesthesia in the United States: A narrative review

BACKGROUND

Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care.

OBJECTIVES

Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed.

EVIDENCE REVIEW

Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks.

FINDINGS

While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce.

CONCLUSION

Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities.

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty

INTRODUCTION

Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't.

MATERIALS AND METHODS

A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05.

RESULTS

48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04).

CONCLUSION

Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

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.

Social risk and patient-reported outcomes after total knee replacement: Implications for Medicare policy

OBJECTIVE

To determine whether county-level or patient-level social risk factors are associated with patient-reported outcomes after total knee replacement when added to the comprehensive joint replacement risk-adjustment model.

DATA SOURCES AND STUDY SETTING

Patient and outcomes data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement cohort were merged with the Social Vulnerability Index from the Centers for Disease Control and Prevention.

STUDY DESIGN

This prospective longitudinal cohort measured the change in patient-reported pain and physical function from baseline to 12 months after surgery. The cohort included a nationally diverse sample of adult patients who received elective unilateral knee replacement between 2012 and 2015.

DATA COLLECTION/EXTRACTION METHODS

Using a national network of over 230 surgeons in 28 states, the cohort study enrolled patients from diverse settings and collected one-year outcomes after the surgery. Patients <65 years of age or who did not report outcomes were excluded.

PRINCIPAL FINDINGS

After adjusting for clinical and demographic factors, we found patient-reported race, education, and income were associated with patient-reported pain or functional scores. Pain improvement was negatively associated with Black race (CI = -8.71, -3.02) and positively associated with higher annual incomes (≥$45,00) (CI = 0.07, 2.33). Functional improvement was also negatively associated with Black race (CI = -5.81, -0.35). Patients with higher educational attainment (CI = -2.35, -0.06) reported significantly less functional improvement while patients in households with three adults reported greater improvement (CI = 0.11, 4.57). We did not observe any associations between county-level social vulnerability and change in pain or function.

CONCLUSIONS

We found patient-level social factors were associated with patient-reported outcomes after total knee replacement, but county-level social vulnerability was not. Our findings suggest patient-level social factors warrant further investigation to promote health equity in patient-reported outcomes after total knee replacement.

Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Postoperative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims

BACKGROUND

Regional anesthesia for total knee arthroplasty has been deemed high priority by national and international societies, and its use can serve as a measure of healthcare equity. The association between utilization of regional anesthesia for postoperative pain and (1) race and (2) hospital in patients undergoing total knee arthroplasty was estimated. The hypothesis was that Black patients would be less likely than White patients to receive regional anesthesia, and that variability in regional anesthesia would more likely be attributable to the hospital where surgery occurred than race.

METHODS

This study used Medicare fee-for-service claims for patients aged 65 yr or older who underwent primary total knee arthroplasty between January 1, 2011, and December 31, 2016. The primary outcome was administration of regional anesthesia for postoperative pain, defined as any peripheral (femoral, lumbar plexus, or other) or neuraxial (spinal or epidural) block. The primary exposure was self-reported race (Black, White, or Other). Clinical significance was defined as a relative difference of 10% in regional anesthesia administration.

RESULTS

Data from 733,406 cases across 2,507 hospitals were analyzed: 90.7% of patients were identified as White, 4.7% as Black, and 4.6% as Other. Median hospital-level prevalence of use of regional anesthesia was 51% (interquartile range, 18 to 79%). Black patients did not have a statistically different probability of receiving a regional anesthetic compared to White patients (adjusted estimates: Black, 53.3% [95% CI, 52.5 to 54.1%]; White, 52.7% [95% CI, 52.4 to 54.1%]; P = 0.132). Findings were robust to alternate specifications of the exposure and outcome. Analysis of variance revealed that 42.0% of the variation in block administration was attributable to hospital, compared to less than 0.01% to race, after adjusting for other patient-level confounders.

CONCLUSIONS

Race was not associated with administration of regional anesthesia in Medicare patients undergoing primary total knee arthroplasty. Variation in the use of regional anesthesia was primarily associated with the hospital where surgery occurred.

EDITOR’S PERSPECTIVE

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series

Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Social determinants of access to timely elective surgery in Ontario, Canada: a cross-sectional population level study

BACKGROUND

Equitable access to surgical care has clinical and policy implications. We assess the association between social disadvantage and wait times for elective surgical procedures in Ontario.

METHODS

We conducted a cross-sectional analysis using administrative data sets of adults receiving nonurgent inguinal hernia repair, cholecystectomy, hip arthroplasty, knee arthroplasty, arthroscopy, benign uterine surgery and cataract surgery from April 2013 to December 2019. We assessed the relation between exceeding target wait times and the highest versus lowest quintile of marginalization dimensions by use of generalized estimating equations logistic regression.

RESULTS

Of the 1 385 673 procedures included, 174 633 (12.6%) exceeded the target wait time. Adjusted analysis for cataract surgery found significantly increased odds of exceeding wait times for residential instability (adjusted odd ratio [OR] 1.16, 95% confidence interval [CI] 1.11-1.21) and recent immigration (adjusted OR 1.12, 95% CI 1.07-1.18). The highest deprivation quintile was associated with 18% (adjusted OR 1.18, 95% CI 1.12-1.24) and 20% (adjusted OR 1.20, 95% CI 1.12-1.28) increased odds of exceeding wait times for knee and hip arthroplasty, respectively. Residence in areas where higher proportions of residents self-identify as being part of a visible minority group was independently associated with reduced odds of exceeding target wait times for hip arthroplasty (adjusted OR 0.82, 95% CI 0.75-0.91), cholecystectomy (adjusted OR 0.68, 95% CI 0.59-0.79) and hernia repair (adjusted OR 0.65, 95% CI 0.56-0.77) with an opposite effect in benign uterine surgery (adjusted OR 1.28, 95% CI 1.17-1.40).

INTERPRETATION

Social disadvantage had a small and inconsistent impact on receiving care within wait time targets. Future research should consider these differences as they relate to resource distribution and the organization of clinical service delivery.

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

Outpatient Total Joint Arthroplasty: Are We Closing the Racial Disparities Gap?

INTRODUCTION

As ne arly half of all total joint arthroplasty (TJA) procedures are projected to be performed in the outpatient setting by 2026, the impact of this trend on health disparities remains to be explored. This study investigated the racial/ethnic differences in the proportion of TJA performed as outpatient as well as the impact of outpatient surgery on 30-day complication and readmission rates.

METHODS

The ACS National Surgical Quality Improvement Program was retrospectively reviewed for all patients who underwent primary, elective total hip and knee arthroplasty (THA, TKA) between 2011 and 2018. The proportion of TJA performed as an outpatient, 30-day complications, and 30-day readmission among African American, Hispanic, Asian, Native American/Alaskan, and Hawaiian/Pacific Islander patients were each compared to White patients (control group). Analyses were performed for each racial/ethnic group separately. A general linear model (GLM) was used to calculate the odds ratios for receiving TJA in an outpatient vs. inpatient setting while adjusting for age, gender, body mass index (BMI), functional status, and comorbidities.

RESULTS

In total, 170,722 THAs and 285,920 TKAs were analyzed. Compared to White patients, non-White patients had higher likelihood of THA or TKA performed as an outpatient (OR 1.31 and 1.24 respectively for African American patients, OR 1.65 and 1.76 respectively for Hispanic patients, and OR 1.66 and 1.59 respectively for Asian patients, p < 0.001). Outpatient surgery did not lead to increased complications in any of the study groups compared to inpatient surgery (p > 0.05). However, readmission rates were significantly higher for outpatient TKA in all the study groups compared to inpatient TKA (OR range 2.47-10.15, p < 0.001). Complication and readmission rates were similar between inpatient and outpatient THA for all the study groups.

CONCLUSION

While this study demonstrated higher proportion of TJA performed as an outpatient among most non-White racial/ethnic groups, this observation should be tempered with the increased readmission rates observed in outpatient TKA, which could further the disparities gap in health outcomes.

Ethical Considerations in Total Joint Arthroplasty

Hip and knee arthroplasty surgeries have excellent outcomes and notably improve quality of life. However, ethical issues permeate the practice of adult reconstruction, and as economics and technology evolve, these issues have become increasingly important. This article will review the currently published literature on ethical issues including industry influences, implants and instrumentations, surgical innovation, new technology adoptions, and healthcare policy-relevant issues, including patient cost sharing and bundled care programs. In addition, the direct marketing of implants from the manufacturer to the general public may falsely raise patient expectations concerning the long-term clinical outcome and performance of newer devices in the absence of long-term studies. This article will also focus on relevant contemporary ethical issues that do not necessarily have preexisting published literature or guidelines but, nonetheless, are crucial for adult reconstruction surgeons to address. These issues include access to care and challenges with orthopaedic resident and fellow education. Surgeons must understand the ethical issues that can arise in their clinical practice and how those issues affect patients. Clinicians are tasked with making the best-reasoned judgment possible to optimize their patients' outcomes. Still, the ability to standardize treatment while optimizing individual outcomes for unique patients remains a challenge.

Determinants of High Facility Costs in Total Joint Arthroplasty Patients: A Time-driven Activity-based Costing Analysis

INTRODUCTION

Although several studies identify risk factors for high-cost patients in an episode of care for total hip (THA) and knee arthroplasty (TKA), few have looked at cost outliers from a facility perspective. The purpose of this study was to use time-driven activity-based costing (TDABC) to identify characteristics of high-cost patients.

METHODS

We reviewed a consecutive series of primary THA and TKA patients by 22 different surgeons at two hospitals between 2015 and 2020. Facility costs were calculated using a TDABC algorithm for their entire hospital stay. Patients in the top decile of costs were considered to be high-cost patients. Multivariate regression was done to identify independent patient factors that predicted high costs.

RESULTS

Of the 8,647 patients we identified, 60.5% underwent THA and 39.5% underwent TKA. Implant purchase price accounted for 49.5% of total inpatient costs (mean $2,880), followed by intraoperative (15.9%, mean $925) and postoperative personnel costs (16.8%, mean $980). Implant price demonstrated the highest variation between high-cost and low-cost groups (4.4 times). Patient-related factors associated with high costs were female sex (OR = 1.332), Hispanic ethnicity (OR = 1.409), American Society of Anesthesiology score (OR = 1.658), need for transfusion (OR = 2.008), and lower preoperative HOOS/KOOS Jr (OR = 1.009).

CONCLUSION

This study identifies several variables for patients at risk to have high facility costs after primary THA and TKA. From the hospital's perspective, efforts to reduce implant purchase prices may translate into substantial cost savings. At the patient level, multidisciplinary initiatives to optimize medical comorbidities, decrease transfusion risk, and control medication expenses in high-risk patients may narrow the existing variation in costs.

Disparities in postoperative total shoulder arthroplasty outcomes between Black and White patients

Background

Despite the rise in surgical volume for total shoulder arthroplasty (TSA) procedures, racial disparities exist in outcomes between White and Black populations. The purpose of this study was to compare 30-day postoperative complication rates between Black and White patients following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent TSA between 2015 and 2019. Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between Black or African American race and postoperative complications.

Results

A total of 19,733 patients were included in the analysis, 18,669 (94.6%) patients in the White cohort and 1064 (5.4%) patients in the Black or African American cohort. Demographics and comorbidities that were significantly associated with Black or African American race were age 40-64 years (P < .001), body mass index ≥40 (P < .001), female gender (P < .001), American Society of Anesthesiologists classification ≥3 (P < .001), smoking status (P < .001), non-insulin and insulin dependent diabetes mellitus (P < .001), hypertension requiring medication (P < .001), disseminated cancer (P = .040), and operative duration ≥129 minutes (P = .002). Multivariate logistic regression identified Black or African American race to be independently associated with higher rates of readmission (odds ratio: 1.42, 95% confidence interval: 1.05-1.94; P = .025).

Conclusion

Black or African American race was independently associated with higher rates of 30-day readmission following TSA.

Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study

INTRODUCTION

Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty.

MATERIALS AND METHODS

Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill).

RESULTS

In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill.

CONCLUSION

In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

Perioperative Outcomes in Total Knee Arthroplasty for Non-English Speakers

BACKGROUND

Many studies have demonstrated that in patients whose primary language is not English, outcomes after an orthopaedic surgery are worse compared to primary English speakers. The goal of this study was to compare perioperative outcomes in patients undergoing total knee arthroplasty (TKA) who prefer English as their first language versus those who prefer a different language.

METHODS

We retrospectively reviewed all patients who underwent primary TKA from May 2012 to July 2021. Patients were separated into two groups based on whether English was their preferred primary language (PPL). Of the 13,447 patients who underwent primary TKA, 11,290 reported English as their PPL, and 2,157 preferred a language other than English. Patients whose PPL was not English were further stratified based on whether they requested interpreter services. Multiple regression analyses were performed to determine the significance of perioperative outcomes while controlling for demographic differences.

RESULTS

Our analysis found that non-English PPL patients had significantly lower rates of readmission (P = .040), overall revision (P = .028), and manipulation under anesthesia (MUA; P = .025) within 90 days postoperatively. Sub analyses of the non-English PPL group showed that those who requested interpreter services had significantly lower 1-year revision (P < .001) and overall MUA (P = .049) rates.

CONCLUSION

Our results demonstrate that TKA patients who communicated in English without an interpreter were significantly more likely to undergo revision, readmission, and MUA. These findings may suggest that language barriers may make it more difficult to identify postoperative problems or concerns in non-English speakers, which may limit appropriate postoperative care.

LEVEL III EVIDENCE

Retrospective Cohort Study.

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States

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.

Disparities in Hand Surgery Exist in Unexpected Populations

Background The purpose of our study is to investigate disparities in the patient populations and outcomes of carpal tunnel release (CTR) and trigger finger release (TFR).  Methods A retrospective review of 777 CTR and 395 TFR patients from May 2021 to August 2022 was completed. The shortened form of the Disabilities of the Arm, Shoulder, and Hand (DASH) scores (QuickDASH) was recorded to evaluate physical function preoperatively and at one and three months postoperatively. This study was deemed institutional review board-exempt by the institutional clinical research committee. Results Compared to CTR, TFR patients resided in zip codes with higher levels of social vulnerability across dimensions of 'household composition and disability' (p=0.018) and 'minority status and language' (p=0.043). When analyzing QuickDASH scores by demographics and procedure, preoperative scores were statistically significantly higher for non-married (p=0.002), White (p=0.003), and female sex (p=0.001) CTR patients. Further, one-month postoperative scores were statistically higher for White and non-married CTR patients (0.016 and 0.015, respectively). At three months postoperatively, female and non-married patients had statistically significant higher scores (0.010 and 0.037, respectively). In TFR patients, one-month postoperative QuickDASH scores for White and female patients were statistically significantly higher (0.018 and 0.007, respectively). There were no significant differences in QuickDASH scores between rural and non-rural patients, household income (HHI) above or below the median, or the Social Vulnerability Index (SVI) dimensions.  Conclusion Our study found marital status, sex, and race were associated with disparities in pre-and postoperative physical function in patients undergoing carpal tunnel or trigger finger release. However, future studies are warranted to confirm and develop solutions to disparities within this population.

A Multilingual Chatbot Can Effectively Engage Arthroplasty Patients with Limited English Proficiency

BACKGROUND

In the United States, English language proficiency is widely accepted as a key social determinant of health. For patients with limited English proficiency (LEP), language barriers can make the delivery of perioperative instructions challenging. The purpose of this study was to evaluate whether a multilingual chatbot could effectively engage LEP patients and improve their outcome after total joint arthroplasty (TJA).

METHODS

We identified 1,282 TJA patients (705 knees, 577 hips) who enrolled in a Short Message Service (SMS) chatbot from 2020-2022. 47 patients enrolled in the chatbot received their messages in a language other than English. A historical control of 68 LEP patients not enrolled in the chatbot was identified. Chi-squared, Fisher's Exact, and t-tests were performed to measure the effect that conversational engagement had on ED visits, hospital readmissions, and reoperations.

RESULTS

There was no difference in the conversational engagement between LEP patients and those with English as their primary language (EPL) (12.3 vs. 12.2 text responses, p=0.959). The LEP cohort who enrolled in the chatbot had fewer readmissions (0% vs. 8.3%, p=0.013) and a near significant reduction in ED visits (0.9% vs. 8.0%, p=0.085) compared to those not enrolled. There was no difference in reoperations between the two cohorts.

CONCLUSIONS

LEP and EPL patients engaged equally with the multilingual chatbot. LEP patients who enrolled in the chatbot had fewer readmissions and a near significant reduction in ED visits. Multilingual platforms such as this chatbot may provide more equitable care to our frequently encountered LEP patients.

Racial/Ethnic Disparities in Physical Therapy Utilization After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities.

METHODS

TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses.

RESULTS

Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each).

DISCUSSION

In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately.

LEVEL OF EVIDENCE

Level III.

Total Joint Arthroplasty Utilization After Orthopaedic Surgery Referral: Identifying Disparities Along the Care Pathway

BACKGROUND

Although racial and ethnic disparities in total joint arthroplasty (TJA) have been thoroughly described, only a few studies have sought to determine exactly where along the care pathway these disparities are perpetuated. The purpose of this study was to investigate disparities in TJA utilization occurring after patients who had diagnosed hip or knee osteoarthritis were referred to a group of orthopaedic providers within an integrated academic institution.

METHODS

A retrospective, multi-institutional study evaluating patients with diagnosed hip or knee osteoarthritis was conducted between 2015 and 2019. Information pertaining to patient demographics, timing of clinic visits, and subsequent surgical intervention was collected. Utilization rates and time to surgery from the initial clinic visit were calculated by race, and logistic regressions were performed to control for various demographic as well as health related variables.

RESULTS

White patients diagnosed with knee osteoarthritis were significantly more likely to receive total knee arthroplasty (TKA) than Black and Hispanic patients, even after adjusting for various demographic variables (Black patients: odds ratio [OR] = 0.63, 95% CI = 0.55-0.72, P = .002; Hispanic patients: OR = 0.69, 95% CI = 0.57-0.83, P = .039). Similar disparities were found among patients diagnosed with hip osteoarthritis who underwent total hip arthroplasty (THA; Black patients: OR = 0.73, 95% CI = 0.60-0.89, P = <.001; Hispanic patients: OR = 0.72, 95% CI = 0.53-0.98, P <.001). There were no differences in time to surgery between races (P > .05 for all).

CONCLUSION

In this study, racial and ethnic disparities in TJA utilization were found to exist even after referral to an orthopaedic surgeon, highlighting a critical point along the care pathway during which inequalities in TJA care can emerge. Similar time to surgery between White, Black, and Hispanic patients suggest that these disparities in TJA utilization may largely be perpetuated before surgical planning while patients are deciding whether to undergo surgery. Further studies are needed to better elucidate which patient and provider-specific factors may be preventing these patients from pursuing surgery during this part of the care pathway.

LEVEL OF EVIDENCE

Level IV.

Lack of Demographic Information in Total Hip Arthroplasty/Total Knee Arthroplasty Randomized Controlled Trial Publications

BACKGROUND

The impact of social determinants of health (SDOH) has been documented in orthopaedic literature. However, there is a lack of data on the inclusion of these variables in orthopaedic studies. Our aim was to investigate how many total hip arthroplasties and total knee arthroplasties randomized controlled trials report SDOH variables such as race, ethnicity, insurance, income, and education within the manuscript.

METHODS

A systematic review was conducted on a PubMed search for randomized controlled trials published from 2017 to 2019 in the Journal of Bone and Joint Surgery, Journal of Arthroplasty, Clinical Orthopaedics and Related Research, and Osteoarthritis and Cartilage. Data collected included publication year, type of surgery, and the inclusion of race, ethnicity, insurance, income, and education.

RESULTS

Of the 72 manuscripts included in the study, 5.6% of the manuscripts mentioned race, 4.2% included race within the demographic table, and 1.4% included ethnicity in the demographic table. Overall, only 5 studies discussed any one of the variables studied and none included any SDOH variables in their multivariable regressions. There were no statistically significant differences on inclusion across journal year (P value = .78), journal name (P value = 1.00), or surgery type (P value = .555).

CONCLUSION

Our findings identify a major shortcoming in the inclusion of SDOH variables in total knee arthroplasty/total hip arthroplasty publications. Their exclusion may be indirectly perpetuating disparities if research that does not use representative patient samples is used in creating health policies and national standards.

LEVEL OF EVIDENCE

Level V.

Comorbidity, Racial, and Socioeconomic Disparities in Total Knee and Hip Arthroplasty at High Versus Low-Volume Centers

INTRODUCTION

The purpose of this study was to compare the epidemiologic and demographic profiles and inpatient postoperative complication and economic outcomes of patients undergoing total joint arthroplasty of the hip and knee (TJA) at high-volume centers (HVCs) versus low-volume centers (LVCs) using a large national registry.

METHODS

This retrospective cohort study used data from the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years or older receiving a primary total hip arthroplasty or total knee arthroplasty were included. Patients were stratified into those undergoing their procedure at HVCs versus LVCs. Epidemiologic, demographic, and inpatient postoperative complications and economic outcomes were comparatively analyzed between groups.

RESULTS

A total of 7,694,331 TJAs were conducted at HVCs while 1,044,358 were conducted at LVCs. Patients at LVCs were more likely to be female, be Hispanic, be non-Hispanic Black, and use Medicare and Medicaid than patients at HVCs. Of the 29 Elixhauser comorbidities examined, 14 were markedly higher at LVCs while 11 were markedly higher at HVCs. Patients who underwent TJA at LVCs were more likely to develop cardiac, respiratory, gastrointestinal, genitourinary, hematoma/seroma, wound dehiscence, and postoperative infection complications and were more likely to die during hospitalization. Patients at HVCs were more likely to develop postoperative anemia. Length of stay and total charges were higher at LVCs compared with HVCs.

DISCUSSION

There are notable differences in the demographics, epidemiologic characteristics, and inpatient outcomes of patients undergoing TJA at HVCs versus LVCs. Attention should be directed to identifying and applying the specific resources, processes, and practices that improve outcomes at HVCs while referral practices and centralization efforts should be mindful to not worsen already existing disparities.

Advocacy for Diversity in Hand Surgery

Diversity in the Hand Surgery workforce improves the quality of care delivered, advances a wider variety of innovation within the field and leads to higher patient satisfaction, greater access to care and patient adherence to advice. An understanding of the data makes a compelling argument for change. Advocacy is necessary to stop the "leaky pipeline" of the loss of diversity in more senior and leadership roles. Hand surgeons who are both women and from underrepresented minority groups are especially vulnerable to bias from the health-care system, with focused support and mentoring required throughout their training and career.

Disparities in Elective and Nonelective Total Hip Arthroplasty

BACKGROUND

Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.

METHODS

Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.

RESULTS

After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.

CONCLUSION

Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.

Recent Trends and Hotspots in Hip Arthroplasty: A Bibliometric Analysis and Visualization Study of Last Five-Year Publications

Objectives

Bibliometric analysis is one of the most prevalent methods for analyzing and predicting research trends of particular subjects. Through a bibliometric analysis, the present study sought to look into and depict the hotspots and research trends in hip arthroplasty research over the previous five years.

Methods

The Web of Science Core Collection database was used to find studies on hip arthroplasty published between 2018 and 2022. The VOS viewer, Cite Space, and Bibliometrix were used to carry out the bibliometric study and network visualization.

Results

During the last five years, 5,708 hip arthroplasty publications were cited 40,765 times. The United States and the Journal of Arthroplasty were the top countries and journals regarding the number of studies, respectively. The top 10 global high-impact documents were determined using the citation ranking and citation burst. The most frequently referenced research revealed the epidemiological aspects of hip arthroplasty, perioperative care after hip arthroplasty, COVID-19, periprosthetic joint infections, opioid medicines, stability, and osteonecrosis were the hot topics in hip arthroplasty research. Keyword burst analysis showed that the research trends in hip arthroplasty through 2022 were patient-reported outcome measures (PROM), depression, racial disparity, and artificial intelligence (AI). The analysis of the subject areas revealed the close connections and relationships between different subject areas, as demonstrated by the figures.

Conclusion

The hip arthroplasty research community is very productive and highly centralized. Periprosthetic joint infection, dual-mobility cups, spinopelvic mobility, direct anterior approach, outpatient total hip arthroplasty, polyethylene, periprosthetic fracture, acetabular defects, tranexamic acid, developmental dysplasia of the hip, and safety-net hospitals were recent trends in hip arthroplasty research. Patient-reported outcome measures, depression, racial disparities, and AI were research hotspots in hip arthroplasty.

Racial Disparities in Outcomes of Total Joint Arthroplasty at a Single Institution: Have We Made Progress?

Background

Health disparities disproportionately affect minority groups across the United States with respect to care access, quality, and outcomes. The aim of this study is to examine existing disparities between white and African American (AA) patients regarding postoperative outcomes following total joint arthroplasty and provide insight into disparity trends over a 9-year period.

Methods

A retrospective review of 16,779 total joint arthroplasty patients at a single institution between January 2013 and December 2021 was performed. Patients were grouped by race as AA or white. Outcomes of interest included length of stay (LOS), home discharge, 30-day emergency department return, and 30-day readmission. Univariate statistics and multivariate regressions were utilized to analyze results.

Results

Significant improvements in LOS and rates of home discharge occurred for both white and AA patients at our institution over a 9-year period, while rates of 30-day emergency department returns and readmissions demonstrated a downward but non-statistically significant trend. Despite these trends, AA patients continued to experience longer lengths of stay, less likelihood of 0- or 1-day LOS, and higher risk of nonhome discharge for most years examined. However, after controlling for demographic and comorbidity differences, the differences between groups narrowed over time resulting in no significant differences in the aforementioned 3 measures by 2021.

Conclusions

Although racial disparities in outcomes are still apparent, over time, the differences in resource utilization between AA and white patients have narrowed. Initiatives aimed at creating healthier communities with increased access to care and the ultimate goal of equitable care must continue to be pursued.