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

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.

Healthcare disparities in adult and pediatric spinal deformity: a state of the art review

PURPOSE

A health disparity refers to a greater disease burden or negative health outcomes influenced by social, economic, and environmental factors. Numerous studies in the surgical literature show that social drivers of health affect health outcomes. Similar disparities may affect treatment and outcomes of spine deformity patients. This study aims to review existing literature on healthcare disparities in patients with spinal deformities.

METHODS

A comprehensive search of articles from 1/2002 to 7/2024 in two databases included keywords and Medical Subject Heading terms: "health disparities," "scoliosis," "social determinant of health," "disparities," "spine deformity," and "race". The 22 studies that met the inclusion criteria were U.S.-based, English-language, peer-reviewed research covering all age groups. Exclusion criteria excluded studies unrelated to spinal deformity and case reports.

RESULTS

The search resulted in 22 potential articles investigating health care disparities in spinal deformity patients. Black patients were noted to present with disease progression compared to White patients. Females have a longer length of stay (LOS) than males. The Black and Hispanic patients had longer LOS than Whites. The privately insured patients were more likely to receive timely care than Medicaid recipients.

CONCLUSION

The consensus across much of the literature reviewed indicate that surgeon volume, hospital volume, sex/gender, race/ethnicity, socioeconomic status, and insurance status impact patient outcomes in adult and pediatric spinal deformity. Prospective studies and solutions to address these disparities are needed.

LEVEL OF EVIDENCE

Level III.

Efficacy and Safety of a Patient Selection Tool for Predicted Discharge at an Ambulatory Surgical Center: A Pilot Study

Background

There is a paucity of validated risk stratification tools to assess which patients can safely and predictably undergo outpatient total hip (THA) or knee arthroplasty (TKA) in an ambulatory surgery center (ASC).

Methods

Our novel patient selection tool was prospectively applied to 190 consecutive primary THA and TKA performed by a single surgeon at a single ASC. We identified the proportion of patients discharged home the same day, those requiring a one-night stay, or those with failed discharge within 23 hours. A retrospective chart review was performed to determine if any demographic parameters were risk factors for an overnight stay.

Results

Overall, 190 (100%) patients selected for outpatient THA and TKA were discharged home within 23 hours. One hundred and four patients (55%) were discharged the same day of surgery, whereas 86 (45%) required overnight stay and were discharged on postoperative day 1. Female sex (odds ratio [OR]: 4.1, 95% confidence interval [CI]: 2.0-8.2, P < .001), THA (OR: 2.5, 95% CI: 1.1-5.5, P = .022), and heavier body mass index (OR: 1.0, 95% CI: 1.0-1.2, P = .022) were identified as independent risk factors for staying overnight in the ASC.

Conclusions

In this pilot study, we found that 100% of outpatient THA and TKA-eligible patients were able to be discharged home by postoperative day 1. Additionally, we found that this selection tool is safe and effective at predicting short-stay discharge in an ASC.

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.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND

In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database.

METHODS

White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities.

RESULTS

A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673).

CONCLUSION

Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

A Systematic Review of the State of Neurosurgical Disparities Research: Past, Present, and Future

BACKGROUND

The social determinants of health, which influence healthcare access, patient outcomes, and population-level burden of disease, contribute to health disparities experienced by marginalized patient populations. In the present study, we sought to evaluate the landscape of health disparities research within neurosurgery.

METHODS

Embase, Ovid-MEDLINE, Scopus, Web of Science, Cochrane Library, and ProQuest Dissertations databases were queried for original research on health disparities regarding access to, outcomes of, and/or postoperative management after neurosurgical procedures in the United States.

RESULTS

Of 883 studies screened, 196 were included, of which 144 had a neurosurgery-affiliated author. We found a significant increase in the number of neurosurgical disparities reports beginning in 2010, with only 10 studies reported before 2010. Of the included studies, 3.1% used prospective methods and 63.8% used data from national registries. The disparities analyzed were racial/ethnic (79.6%), economic/socioeconomic (53.6%), gender (18.9%), and disabled populations (0.5%), with 40.1% analyzing multiple or intersecting disparities. Of the included reports, 96.9% were in phase 1 (detecting phase of disparities research), with a few studies in phase 2 (understanding phase), and none in phase 3 (reducing phase). The spine was the most prevalent subspecialty evaluated (34.2%), followed by neuro-oncology (19.9%), cerebrovascular (16.3%), pediatrics (10.7%), functional (9.2%), general neurosurgery (5.1%), and trauma (4.1%). Senior authors with a neurosurgical affiliation accounted for 79.2% of the reports, 93% of whom were academically affiliated.

CONCLUSIONS

Although a recent increase has occurred in neurosurgical disparities research within the past decade, most studies were limited to the detection of disparities without understanding or evaluating any interventions for a reduction in disparities. Future research in neurosurgical disparities should incorporate the latter 2 factors to reduce disparities and improve outcomes for all patients.