Frailty, Race/Ethnicity, Functional Status, and Adverse Outcomes After Total Hip/Knee Arthroplasty: A Moderation Analysis

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 and Ethnic Disparities in Primary Total Knee Arthroplasty Outcomes: A Systematic Review and Meta-Analysis of Two Decades of Research

Racial disparities in outcomes following total knee arthroplasty (TKA) remain persistent. This systematic review and meta-analysis aims to comprehensively synthesize data between 2000-2020. An electronic search of studies was performed on PubMed, SCOPUS, and the Cochrane Library databases from January 1, 2000, and December 31, 2020. Random effects models were used to report unadjusted and adjusted estimates for a comprehensive list of care outcomes in TKA. 63 studies met PRISMA criteria. Black patients report greater odds of in-hospital mortality (odds ratio [OR]: 1.37, 95% CI: 1.00-1.59 (p = 0.049); adjusted OR [aOR]: 1.34, 95% CI: 1.09-1.64), in-hospital complications (OR: 1.31, 95% CI: 1.27-1.35), 30-day complications (aOR: 1.19, 95% CI: 1.07-1.33), infection (OR: 1.11, 95% CI: 1.07-1.16; aOR: 1.30, 95% CI: 1.16-1.46), bleeding (OR: 1.33, 95% CI: 1.03-1.71; aOR: 1.47, 95% CI: 1.23-1.75), peripheral vascular events (PVE) (aOR: 1.46, 95% CI: 1.11-1.92), length of stay (LOS) (OR: 1.20, 95% CI: 1.08-1.34), extended-LOS (aOR: 1.89, 95% CI: 1.53-2.33), discharge disposition (OR: 1.59, 95% CI: 1.29-1.96; aOR: 1.96, 95% CI: 1.70-2.25), 30-day (OR: 1.20, 95% CI: 1.13-1.27; aOR: 1.17 95% CI: 1.09-1.26) and 90-day (OR: 1.46, 95% CI: 1.17-1.82) readmission compared to White patients. Disparities in bleeding, extended-LOS, discharge disposition, PVE, and 30-day readmission were observed in Asian patients. Hispanic patients experienced disparities in extended LOS and discharge disposition, while Native-American patients had disparities in bleeding outcomes. Persistent racial disparities in TKA outcomes highlight a need for standardized outcome measures and comprehensive data collection across multiple racial groups to ensure greater healthy equity.

Preoperative frailty predicts postoperative pain after total knee arthroplasty in older patients: a prospective observational study

PURPOSE

Frailty is reportedly associated with postoperative adverse outcomes and may increase the risk of post-surgical pain. Our study aimed to explore whether frailty was an independent risk factor for pain after total knee arthroplasty (TKA) in older patients.

METHODS

Included in this prospective observational study were patients aged 65 or older who underwent primary TKA. Frailty of the patients was assessed before surgery using the comprehensive geriatric assessment-frailty index and pain was evaluated before and after surgery using the Numerical Rating Scale.

RESULTS

Of the 164 patients including 125 females with a mean age of 71.4 ± 4.6 years, 51 patients were identified as being frail. Patients with chronic post-surgical pain had a significantly higher frailty index than those without chronic post-surgical pain, which was the same in patients with acute post-surgical pain. After adjusting for other confounding factors, frailty was shown to be an independent risk factor for both acute (OR: 13.23, 95% CI 3.73-46.93, P < 0.001) and chronic post-surgical pain (OR: 4.24, 95% CI 1.29-14.00, P = 0.02). The area under the receiver operating characteristic curve for frailty predicting chronic post-surgical pain was 0.73 (P < 0.001, 95% CI 0.65-0.81).

CONCLUSIONS

Our findings demonstrated that preoperative frailty in older patients was a predictor of acute and chronic post-surgical pain after TKA, suggesting that frailty assessment should become a necessary procedure before operations, especially in older patients.

Frailty Among Revision Total Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes

BACKGROUND

Frailty has been shown to correlate with worse outcomes after total knee arthroplasty (TKA), although less is known regarding its effect on revision TKA (rTKA). This study examines the epidemiologic characteristics and inpatient outcomes of patients with frailty undergoing rTKA.

METHODS

Discharge data from National Inpatient Sample registry were used to identify all patients aged 50 years or older who underwent rTKA between 2006 and 2015. Patients were stratified into frail and nonfrail groupings, based on the presence of specific International Classification of Diseases-9 diagnostic coding. An analysis comparing the epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes of the two groups was done.

RESULTS

From 2006 to the third quarter of 2015, a total of 576,920 patients (17,727 frail) who underwent rTKA were included. The average age in the study's population was 67.2 years, with a female distribution of 57.4%. Frail patients were more likely to exhibit markedly higher rates of almost all modified Elixhauser Comorbities than their nonfrail counterparts. Frail patients were also more likely to undergo different types of revisions, including an increased rate of removal of the prosthesis without replacement. In addition, frail patients displayed increased likelihood of experiencing any postoperative complication, deep vein thrombosis, postoperative anemia, respiratory complications, and wound dehiscence. Frail patients experienced lower rates of discharge home and increased length of stay than the nonfrail cohort.

DISCUSSION

Patients with frailty undergoing rTKA are at markedly higher risk for inpatient postoperative complications and increased length of stay. Understanding the implications of frailty within rTKA is essential for risk assessment and preoperative optimization for this expanding population.

Socioeconomic Influence on Cervical Fusion Outcomes

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

The aim of this study was to compare postoperative outcomes following cervical fusion based on socioeconomic status (SES) variables including race, education, net worth, and homeownership status.

SUMMARY OF BACKGROUND DATA

Previous studies have demonstrated the effects of patient race and income on outcomes following cervical fusion procedures. However, no study to date has comprehensively examined the impact of multiple SES variables. We hypothesized that race, education, net worth, and homeownership influence important outcomes following cervical fusion.

MATERIALS AND METHODS

Optum's de-identified Clinformatics Data Mart (CDM) database was queried for patients undergoing first-time inpatient cervical fusion from 2003 to 2021. Patient demographics, SES variables, and the Charlson comorbidity index were obtained. Primary outcomes were hospital length of stay and 30-day rates of reoperation, readmission, and postoperative complications. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges.

RESULTS

A total of 111,914 patients underwent cervical spinal fusion from 2003 to 2021. Multivariate analysis revealed that after controlling for age, sex, and Charlson comorbidity index, Black race was associated with a higher rate of 30-day readmissions [odds ratio (OR): 1.11, 95% CI: 1.03-1.20]. Lower net worth (vs. >$500K) and renting (vs. owning a home) were significantly associated with both higher rates of 30-day readmissions (OR: 1.29, 95% CI: 1.17-1.41; OR: 1.34, 95% CI: 1.22-1.49), and emergency room visits (OR: 1.29, 95% CI: 1.18-1.42; OR: 1.11, 95% CI: 1.00-1.23). Lower net worth (vs. >$500K) was also associated with increased complications (OR: 1.22, 95% CI: 1.14-1.31).

CONCLUSION

Socioeconomic variables, including patient race, education, and net worth, influence postoperative metrics in cervical spinal fusion surgery. Future studies should focus on developing and implementing targeted interventions based on patient SES to reduce disparity.

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty

BACKGROUND

Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA.

METHODS

There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations.

RESULTS

Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002).

CONCLUSIONS

Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.

Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database

BACKGROUND

The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups.

METHODS

This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates.

RESULTS

Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites.

CONCLUSION

There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Patient Designation Prior to Total Knee Arthroplasty: How Can Preoperative Variables Impact Postoperative Status?

BACKGROUND

Removal of total knee arthroplasty (TKA) from the inpatient only list has led to a greater focus on outpatient (OP) procedures. However, the impact of OP-centered models in at-risk patients is unclear. Therefore, the current analysis investigated the effect of conversion from OP to inpatient (IP) status on postoperative outcomes and determined which factors put patients at risk for status change postoperatively.

METHODS

We retrospectively reviewed all patients who underwent a primary TKA at our institution between January 2, 2018, and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions was used to determine factors predictive of status conversion.

RESULTS

Of the 2,313 patients originally designated for OP TKA, 627 (27.1%) required a stay of 2 midnights or longer. Patients in the IP group had significantly higher facility discharge rates (P < .001) compared to the OP group. Factors predictive of conversion included age of 65 years and older (P < .001), women (P < .001), arriving at the postanesthesia care unit after 12 pm (P < .001), body mass index greater than 30 (P = .004), and Charlson Comorbidity Index of 4 and higher (P = .004). Being the first case of the day (P < .001) and being married (P < .001) were both protective against conversion.

CONCLUSION

Certain intrinsic patient factors may predispose a patient to an IP stay, and an understanding of predisposing factors which could lead to IP conversion may improve perioperative planning moving forward.

Does cumulative psychosocial stress explain frailty disparities in community-dwelling older adults?

OBJECTIVE

Frailty is a leading predictor of adverse outcomes in older adults. Although disparities in frailty are well-documented, it is unclear whether psychosocial stressors explain these disparities. This study aimed to examine the potential mediating role of psychosocial stress.

METHODS

This cross-sectional study included 7,679 community-dwelling older adults (≥ 65) from Health and Retirement Study in the US (2006 and 2008). We used six dichotomized psychosocial stressors: a) loneliness, b) discrimination, c) financial strain, d) low subjective status, e) poor neighborhood cohesion, and f) traumatic life events to compute cumulative psychosocial stress. The Fried frailty phenotype defined frailty based on three features: slowness, poor strength, weight loss, fatigue, and low physical activity. Multivariable regressions were used to examine the structural determinants (gender, education, race, and ethnicity) frailty relationship and test whether cumulative psychosocial stress has a mediating role.

RESULTS

The frailty prevalence was 22%. Females, Hispanics, Blacks, and those with less education had higher odds of frailty (p<.01). Race and ethnic minorities and non-college graduates experienced greater cumulative psychosocial stress relative to their White and college graduate counterparts (p<.05), respectively. Greater cumulative psychosocial stress was associated with increased odds of frailty (p < .001); however, it did not mediate the structural determinants and frailty relationship.

CONCLUSION

Contrary to expectations, cumulative psychosocial stress did not mediate the relationship between structural determinants and frailty. Rather, high cumulative psychosocial stress was independently associated with frailty. Further research should examine other psychosocial mediators to inform interventions to prevent/delay frailty.

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.

Frailty Among Total Hip and Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes

INTRODUCTION

Total joint arthroplasty (TJA) is one of the most successful and frequently performed procedures in the United States. The number of these procedures is projected to continue growing rapidly in the coming years, and with it comes the demand for more sophisticated perioperative risk and complication assessment. This study examines the effect of frailty on postoperative inpatient complications and hospital resource utilization after TJA.

METHODS

Discharge data from the National Inpatient Sample were used to identify all patients aged 50 years or older who underwent TJA between 2006 and 2015. Nonelective admissions and hip fractures were excluded. Patients were stratified into two groups with and without concomitant ICD-9 diagnostic criteria that qualified them has having frailty. An analysis comparing the 2 groups' epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes was done.

RESULTS

A total of 7,854,890 TJAs were included in this analysis, with 136,516 meeting the criteria for frailty and 7,718,374 being nonfrail. Among these patients, the average age was 67.3 years and the female distribution was 61.1%. Frail patients were found to have markedly higher rates of all but two individual comorbidities constituting the Modified Elixhauser Profile compared with nonfrail patients. Compared with the control group, frail patients were found to have increased risk of any postoperative complication, central nervous system complications, hematoma/seroma, wound dehiscence, infection, and postoperative anemia. Frail patients also had longer length of stay, higher discharge to rehabilitation facilities, and higher hospital charges.

DISCUSSION

Patients with frailty undergoing TJA procedures are at a markedly higher risk for developing postoperative complications and worse hospital economic outcomes. As this patient population continues to increase, it is imperative for clinicians to use their risk factors in optimizing their perioperative care and support.

Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis

BACKGROUND

Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable.

CONCLUSION

Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care.

LEVEL OF EVIDENCE

IV.

Pre- and Post-Operative Rehabilitation Interventions in Patients at Risk of Poor Outcomes Following Knee or Hip Arthroplasty: Protocol for Two Systematic Reviews

Objective

Total knee (TKA) and hip arthroplasty (THA) are successful procedures in treating end-stage osteoarthritis when nonoperative treatments fail. However, a growing body of literature has been reporting suboptimal outcomes following TKA and THA. While pre- and post-operative rehabilitation is imperative to recovery, little is known about their effectiveness for patients at risk of poor outcomes. In the 2 systematic reviews with identical methodology, we aim to evaluate the effectiveness of (a) pre-operative and (b) post-operative rehabilitation interventions for patients at risk of poor outcomes following TKA and THA.

Methods

The 2 systematic reviews will follow the principles and recommendations outlined in the Cochrane Handbook. Only randomized controlled trials (RCTs) and pilot RCTs will be searched in 6 databases: CINAHL, MEDLINE, Embase, Web of Science, Pedro, and OTseeker. Eligible studies including patients at risk of poor outcomes and evaluating rehabilitation interventions following and preceding arthroplasty will be considered for inclusion. Primary outcomes will include performance-based tests and functional patient-reported outcome measures, and secondary outcomes will include health-related quality of life and pain. The quality of eligible RCTs will be evaluated using the Cochrane's risk of bias tool, and the strength of evidence will be assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE).

Discussion

These reviews will synthesize the evidence regarding the effectiveness of pre-and post-operative rehabilitation interventions for patients at risk of poor outcomes, which in turn may inform practitioners and patients in planning and implementing the most optimal rehabilitation programs to achieve the best outcomes after arthroplasty.

Systematic Review Registration

PROSPERO CRD42022355574.

Frailty among older Hispanics living in the United States: A scoping review

A scoping review was conducted to identify the available evidence about frailty among older Hispanics living in the U.S. using the Integral Model of Frailty. A not time-limited search was conducted in five peer-reviewed databases. Identified factors associated with frailty among older Hispanics are presented in four categories: (1) Characteristics and prevalence of frailty, (2) Life course determinants of frailty, (3) Comorbidities associated with frailty, and (4) Adverse outcomes of frailty. A total of 1030 articles were identified, and 37 articles were included in the scoping review. Most studies measured frailty based on the Fried Frailty Phenotype (59.5%, n= 22) and had a longitudinal design (64.9%, n= 24). The overall prevalence of frailty among Hispanics ranged from 4.3% to 37.1% (n= 20 studies). Further research is needed that targets Hispanics from different backgrounds in the U.S., particularly those that are high in number (i.e., Mexicans, Puerto Ricans, and Central Americans).

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities

BACKGROUND

Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States.

METHODS

A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data.

RESULTS

A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05).

CONCLUSIONS

This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty

BACKGROUND

There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis.

METHODS

From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA.

RESULTS

Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001).

CONCLUSION

THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.