Emerging Racial Disparities in Outpatient Utilization of Total Joint Arthroplasty

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.

Higher socioeconomic status is associated with greater rates of surgical resource utilization prior to spine fusion surgery

BACKGROUND CONTEXT

Previous research has demonstrated an association between socioeconomic status (SES) and patient health, specifically noting that patients of lower SES have poor health outcomes. Understanding how social factors, including socioeconomic status (SES), relate to disparities in health outcomes is critical to closing gaps in equitable care to patients. While several studies have examined the effect of SES on postoperative spine outcomes, there is limited spine literature evaluating SES in the context of barriers to spine care.

PURPOSE

The primary objective of this study was to determine if socioeconomic status is associated with resource utilization prior to spine surgery consultation. As part of a subanalysis, this paper also explores the effect of other social factors on previsit resource utilization.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients who underwent elective cervical or lumbar spinal fusion between 2020 and 2021.

OUTCOME MEASURES

Previsit resource utilization including 1) epidural steroid injection, 2) opioid use, 3) physical therapy, 4) prior spine surgeon, and 5) prior spine surgery.

METHODS

Each patient was assigned a "distressed score" using the Distressed Communities Index (DCI) and a socioeconomic status (SES) score using the Social Vulnerability Index (SVI) based on their zip code. Patient charts were manually reviewed to collect data regarding previsit resource utilization. The cohort was analyzed based on DCI quintile and SVI quartile. Additional analyses were conducted based on marital status and race.

RESULTS

Our study included 996 patients in the final analysis. Based on DCI, patients from prosperous communities were more likely to have previously visited a spine surgeon (13.2% (prosperous) vs 7.58% vs 6.92% vs 9.09% vs 3.70% (distressed), p=.015) and to have had prior spine surgery (11.1% (prosperous) vs 9.57% vs 9.09% vs 2.52% vs 6.36% (distressed), p=.015). Similarly, when evaluated based on SES SVI, patients who lived in a low-risk community were more likely to have previously visited a spine surgeon (13.0% low-risk vs 7.26% low-medium risk vs 16.9% medium-high risk vs 10.6% high risk, p=.049) and to have had prior spine surgery (13.0% low-risk vs 7.26% vs 16.9% vs 10.6% high risk, p=.030). When evaluated based on marital status, there was no difference in any resource utilization. Non-Black and non-White patients were more likely to have tried physical therapy compared to their black and white counterparts (76.9% (other) vs 60.9% (Black) vs 54.3% (White), p=.026).

CONCLUSION

This study examined the relationship between socioeconomic status and resource utilization and found a positive correlation between higher social standing and access to spine surgery and spine surgeons. These findings demonstrate a propensity for earlier evaluation of spine-related conditions among patients from prosperous communities compared to patients from less prosperous communities.

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.

Ask, Acknowledge, Ascend: Addressing Mistrust as a Strategy to Address Disparities in Orthopaedic Ambulatory Care

Advances in minimally invasive surgical techniques, robotics, anesthesia techniques, and recovery protocols have been instrumental in shifting orthopaedic surgical care from the hospital-based operating room to ambulatory surgical centers. Outpatient surgical services are thought to offer a lower-cost model of care, reduced out-of-pocket expenses, more predictable scheduling, faster recovery times, convenience, and lower risk of nosocomial infections. With these known advantages, it is critical to examine whether this safer environment is accessible to all. Racial/ethnic and gender disparities have been well-documented in the inpatient orthopaedic environment and concern has been raised that the shift toward outpatient surgery could widen disparities and access to care. This article describes ongoing disparities in ambulatory orthopaedic surgery for racialized minorities, women, and people with obesity. Having experienced these disparities, many lack trust in health care providers and the health system. Approaches for addressing this mistrust to create meaningful patient-centered care are described.

The impact of social deprivation on healthcare utilization patterns following rotator cuff repair

BACKGROUND

Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized.

METHODS

This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared.

RESULTS

A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients.

CONCLUSIONS

Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do?

PURPOSE OF REVIEW

Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes.

RECENT FINDINGS

Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

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.

Identifying Racial Disparities in Utilization and Clinical Outcomes of Ambulatory Hip Arthroscopy: Analysis of Temporal Trends and Causal Inference via Machine Learning

Background

Arthroscopic diagnosis and treatment of femoroacetabular pathology has experienced significant growth in the last 30 years; nevertheless, reduced utilization of orthopaedic procedures has been observed among the underrepresented population.

Purpose/Hypothesis

The purpose of this study was to examine racial differences in case incidence rates, outcomes, and complications in patients undergoing hip arthroscopy. It was hypothesized that racial and ethnic minority patients would undergo hip arthroscopy at a decreased rate compared with their White counterparts but that there would be no differences in clinical outcomes.

Study Design

Cross-sectional study.

Methods

The State Ambulatory Surgery and Services Database and the State Emergency Department Database of New York were queried for patients undergoing hip arthroscopy between 2011 and 2017. Patients were stratified into White and racial and ethnic minority races, and intergroup comparisons were performed for utilization over time, total charges billed per encounter, 90-day emergency department (ED) visits, and revision hip arthroscopy. Temporal trends in the utilization of hip arthroscopy were identified, and racial differences in secondary outcomes were analyzed with a semiparametric method known as targeted maximum likelihood estimation (TMLE) backed by a library of machine learning algorithms.

Results

A total of 9745 patients underwent hip arthroscopy during the study period, with 1081 patients of minority race (11.1%). White patients underwent hip arthroscopy at 5.68 (95% CI, 4.98-6.48) times the incidence rate of racial and ethnic minority patients; these incidence rates grew annually at a ratio of 1.11 in White patients compared with 1.03 in racial and ethnic minority patients (P < .001). Based on the TMLE, racial and ethnic minority patients were significantly more likely to incur higher costs (P < .001) and visit the ED within 90 days (P = .049) but had negligible differences in reoperation rates at a 2-year follow-up (P = .53). Subgroup analysis identified that higher likelihood for 90-day ED admissions among racial and ethnic minority patients compared with White patients was associated with Medicare insurance (P = .002), median income in the lowest quartile (P = .012), and residence in low-income neighborhoods (P = .006).

Conclusion

Irrespective of insurance status, racial and ethnic minority patients undergo hip arthroscopy at a lower incidence and incur higher costs per surgical encounter.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting

BACKGROUND CONTEXT

Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated.

PURPOSE

This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021.

OUTCOME MEASURES

Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality.

METHODS

A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences.

RESULTS

Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all).

CONCLUSIONS

Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

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.

Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends

Background

While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon.

Methods

The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts.

Results

Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001).

Conclusion

To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.

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.

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.

Improved Accuracy/Completeness of EHR Race/Ethnicity Data: A Requisite Step to Address Disparities in Care

Accurate and complete racial/ethnic data in the electronic health record are a requisite step to addressing disparities in neurologic care, and at local, regional, and national levels. The current data pertaining to the patients' race and ethnicity contained in the electronic health record are inadequate. This article outlines recommendations at the individual practice and electronic health record vendor level to improve documentation of race and ethnicity.

Successful Transition to Same Calendar Day Discharge in Total Joint Arthroplasty at an Academic Center

Background

There has been a shift toward same-day discharge (SDD) in total joint arthroplasty (TJA) in recent years. Our clinical standard had been next-day discharge, but the COVID pandemic led to a hospital bed shortage, causing us to shift to SDD directly from the Post-Anesthesia Care Unit (PACU). The aim of our project was to investigate if the SDD protocol was successful and if it changed complications or 90-day readmission rates. Our secondary aim was to investigate if the protocol created disparities in patient selection.

Methods

A retrospective review compared the first 100 patients intended to discharge from PACU to the 100 patients prior to the SDD protocol undergoing elective primary TJA procedures at our academic institution from September 1, 2020, to March 23, 2021. The SDD protocol started on November 19, 2020.

Results

During this SDD period, 98% (98/100) of patients were successfully discharged from the PACU. The 90-day readmission rate changed from 0% to 2% (P = .4975), and the overall complication rate changed from 2% to 5% (P = .4448). Most complications were manipulation under anesthesia to improve range of motion. Manipulations under anesthesia changed from 1% to 4% (P = .3687).

Conclusions

The transition to same SDD in TJA at our academic institution was successfully implemented without markedly increasing complications, readmissions, or changing patient selection. The COVID-19 pandemic likely influenced the recovery of patients before and after the protocol. Future studies are needed to validate this data during the post-COVID era.

A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital

BACKGROUND

There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital.

METHODS

A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours.

RESULTS

We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%.

CONCLUSION

In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.

The Impact of the COVID-19 Pandemic on the Practice of Hip and Knee Arthroplasty

» The COVID-19 global pandemic resulted in unprecedented disruptions in care including massive surgical cancelations, a shift to outpatient surgery, and novel medical risks posed by COVID-19 infection on patients undergoing joint replacement surgery.» Refined patient optimization pathways have facilitated safe, efficient outpatient total joint arthroplasty in patient populations that may not otherwise have been considered eligible.» Rapid innovations emerged to deliver care while minimizing the risk of disease transmission which included the widespread adoption of telemedicine and virtual patient engagement platforms.» The widespread adoption of virtual technology was similarly expanded to resident education and continuing medical activities, which has improved our ability to propagate knowledge and increase access to educational initiatives.» Novel challenges borne of the pandemic include profound personnel shortages and supply chain disruptions that continue to plague efficiencies and quality of care in arthroplasty and require creative, sustainable solutions.

Race Associated With Increased Complication Rates After Total Knee Arthroplasty

BACKGROUND

Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications.

METHODS

A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients.

RESULTS

The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455).

CONCLUSION

Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

METHODS

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

RESULTS

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

CONCLUSION

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

Value of Ambulatory Modified Radical Mastectomy

BACKGROUND

Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM.

METHODS

Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission.

RESULTS

Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01).

CONCLUSIONS

The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

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.

Race and Sex Disparities in Lower Extremity Total Joint Arthroplasty: A Retrospective Database Study

INTRODUCTION

Total joint arthroplasty (TJA) is successful in improving health-related quality of life. However, outcomes vary in the literature due to modifiable and non-modifiable factors. Modifiable factors consist of body mass index (BMI), nutrition, and tobacco use. Non-modifiable risk factors include age, race, sex, and socioeconomic status. Prior literature has focused on racial disparities in terms of the utilization of lower extremity arthroplasty. The purpose of this study is to determine the effect of race and sex on the in-hospital complication rate, length of stay, and charges associated with primary TJA.

METHODS

This retrospective cohort utilized complex survey data from the National Inpatient Sample (NIS) between 2016 and 2019. The use of the International Classification of Disease-10 Procedure Codes (ICD-10 PCS) for right hip, left hip, right knee, and left knee TJA yielded a preliminary total of 2,660,280 patients. The exclusion criteria were bilateral arthroplasty and concomitant unilateral hip and knee arthritis. Major complications were defined as acute myocardial infarction, cardiac arrest, pulmonary embolism, adult respiratory distress syndrome, stroke, shock, and septicemia. Odds ratio (OR) and beta coefficients were adjusted for age, sex, primary payer, hospital region, hospital teaching status, and year. Total charges were adjusted for inflation using the Consumer Price Index data reported by the US Bureau of Labor Statistics.

RESULTS

A total of 2,589,510 patients met our inclusion criteria; 87.6%, 5.9%, 4.8%, 1.4%, and 0.3% of people were 'White', 'Black', 'Hispanic', 'Asian, or Pacific Islander', and 'Native American', as defined by the National (Nationwide) Inpatient Sample (NIS) Variable 'RACE'. Black individuals experienced a significantly greater major complication rate compared to White individuals (0.87% vs. 0.74%, OR 1.25, p-value = 0.0004). Black and Hispanic individuals experienced a significantly greater minor complication rate compared to White individuals (6.39% vs. 4.12%, odds ratio (OR) 1.61, p-value < 0.0001; 4.68% vs. 4.12%, OR 1.17, p-value < 0.0001). Black, Hispanic, Asian or Pacific Islander, and Native American individuals stayed, on average, 0.33, 0.19, 0.19, and 0.25 days longer than White individuals (2.78, 2.54, 2.55, 2.56 vs. 2.37 days, p<0.0001). None of these statistically significant differences exceeded the established minimal clinically important difference of two days. Black, Hispanic, and Asian or Pacific Islander patients were charged $5,751, $18,656, and $12,119 more than White patients ($72,122, $85,027, $78,490, and $59,297 vs. $66,371, p ≤ 0.0165). Native American patients were charged $7,074 less than White patients ($59,297 vs. $66,371, p < 0.0001).

CONCLUSIONS

Black and Hispanic TJA patients may have higher complication rates than White TJA patients. The differences in length of stay between race groups may not affect outcomes. Hispanic patients received significantly more charges than White patients, and Native American patients received significantly fewer charges than White patients after controlling for non-modifiable risk factors. Addressing the charge disparities may reduce the total national cost burden associated with TJA. The present study highlights the need for further studies on healthcare outcomes related to race and sex.

Diversity in Orthopaedic Surgery Medical Device Clinical Trials: An Analysis of the Food and Drug Administration Safety and Innovation Act

INTRODUCTION

Demographic factors contribute markedly to orthopaedic surgery outcomes. However, women and minorities have been historically excluded from clinical trials. The United States passed the Safety and Innovation Act (Food and Drug Administration Safety and Innovation Act [FDA-SIA]) in 2012 to increase study diversity and mandate reporting of certain demographics. The purpose of this study was to investigate demographic reporting and analysis among high-risk orthopaedic medical device trials and evaluate the effectiveness of the FDA-SIA in increasing diversity of study enrollment.

METHODS

The premarket approval database was queried for all original submissions approved by the Orthopedic Advisory Committee from January 1, 2003, to July 1, 2022. Study demographics were recorded. Weighted means of race, ethnicity, and sex were compared before and after FDA-SIA implementation with the US population.

RESULTS

We identified 51 orthopaedic trials with unique study data. Most Food and Drug Administration device trials reported age (98.0%) and sex (96.1%), but only 49.0% and 37.3% reported race and ethnicity, respectively. Only 23 studies analyzed sex, six analyzed race, and two analyzed ethnicity. Compared with the US population, participants were overwhelmingly White (91.36% vs. 61.63%, P < 0.001) with a significant underrepresentation of Black (3.65% vs. 12.41%, P = 0.008), Asian (0.86% vs. 4.8%, P = 0.030), and Hispanic participants (3.02% vs. 18.73%, P < 0.001) before 2013. The FDA-SIA increased female patient enrollment (58.99% vs. 47.96%, P = 0.021) but did not increase the enrollment of racial or ethnic minorities.

CONCLUSION

Despite efforts to increase the generalizability of studies within the FDA-SIA, orthopaedic medical devices still fail to enroll diverse populations and provide demographic subgroup analysis. The study populations within these trials do not represent the populations for whom these devices will be indicated in the community. The federal government must play a stronger role in mandating study diversity, enforcing appropriate statistical analysis of the demographic subgroups, and executing measures to ensure compliance.

LEVEL OF EVIDENCE

I.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians

BACKGROUND

One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old.

METHODS

This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed.

RESULTS

Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days.

CONCLUSION

Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.