Total Versus Unicondylar Knee Arthroplasty: Does Race Play a Role in the Treatment Selection?

Racial, socioeconomic, and payer status disparities in utilization of unicompartmental knee arthroplasty in the USA

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is a surgical treatment for knee osteoarthritis associated with lower morbidity compared with total knee arthroplasty (TKA) in patients with isolated unicompartmental knee arthritis. As disparities have been noted broadly in arthroplasty care, it follows that such disparities might be present in the utilization of UKA relative to TKA. This study therefore examined racial/ethnic, socioeconomic, and payer status differences in utilization of UKA.

METHODS

Patients who underwent UKA or TKA between 2016 and 2020 in the National Inpatient Sample were identified. Multivariable Poisson regression models adjusted for hospital geographic region and patient characteristics [age, sex, and Elixhauser Comorbidity Index (ECI)] were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on incidence rate ratio of UKA relative to TKA.

RESULTS

Of the 8472 UKA patients and 639,937 TKA patients identified between 2016 and 2020, 8027 (94.7%) UKA patients and 606,028 (94.7%) TKA patients met inclusion criteria. Patients who underwent UKA were significantly younger (63.5 ± 10.7 years) than patients who underwent TKA (66.8 ± 9.5 years; p < 0.001) and had significantly lower ECI scores (1.8 ± 1.5) than patients who underwent TKA (2.2 ± 1.6; p < 0.001). Black patients were less likely to undergo UKA relative to TKA compared with white patients [incidence rate ratio (IRR) 0.64, confidence interval (CI) 0.58-0.71, p < 0.001]. Compared with patients in income quartile 4, patients in income quartiles 1 and 2 underwent UKA at a lower relative rate (IRR 0.85, CI 0.79-0.90, p < 0.001 and IRR 0.87, CI 0.82-0.93, p < 0.001, respectively). Compared with patients with private insurance, patients with Medicare underwent UKA at a lower relative rate (IRR 0.83, CI 0.79-0.88, p < 0.001).

CONCLUSIONS

Black patients, lower-income patients, and Medicare-insured patients undergo UKA at a lower relative rate than white, higher-income, and privately insured patients, respectively. Further research may help elucidate reasons for these differences and identify targets for intervention.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BACKGROUND

Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.

METHODS

Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.

RESULTS

Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.

CONCLUSIONS

Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

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.

Post-operative outcomes in Indigenous patients in North America and Oceania: A systematic review and meta-analysis

Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative mortality. Several gaps in data exist regarding global differences in surgical morbidity and mortality for Indigenous populations based on geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative outcomes between Indigenous and non-Indigenous populations. This systematic review and meta-analysis was conducted in accordance with PRISMA and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n = 31, North America n = 36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients had 1.26 times odds of post-operative morbidity (OR = 1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times odds of post-operative infection (OR = 1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times odds of reoperation (OR = 1.33, 95% CI: 1.02-1.74, p = 0.04). In conclusion, we found that Indigenous patients in North American and Oceania experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there is a low proportion of high-quality research focusing on assessing surgical equity for Indigenous patients in these regions, despite multiple international and national calls to action for reconciliation and decolonization to improve quality surgical care for Indigenous populations.