Effects of deprivation, ethnicity, gender and age on distal radius fracture incidence and surgical intervention rate

Are Clinical Practice Guidelines Representative of Patients with Distal Radius Fractures? A Review of Patient Demographics and Patient-Reported Outcome Measures Used to Inform Guidelines

PURPOSE

Clinical practice guidelines (CPGs) are recommendations developed for broad application to optimize high-quality care and decision-making. The composition of patients and outcome measures used in studies informing CPGs; however, has not been rigorously evaluated. With growing evidence that outcomes in musculoskeletal surgery vary by sociocultural factors, we aimed to: (1) review the linguistic, racial, and ethnic representation of the patients in the studies informing CPGs for distal radius fractures and (2) assess their use of linguistically and culturally adapted patient-reported outcome measures (PROMs).

METHODS

The American Academy of Orthopaedic Surgeons website was used to identify relevant studies. Key variables were extracted, including inclusion and exclusion criteria, language of study, patient language and proficiency, patient race and ethnicity, and use of translated or culturally adapted PROMs. If provided, the clinical trial registration page for the study was evaluated. Descriptive statistics were used to describe the frequency of each variable.

RESULTS

Fifty-four published texts were evaluated. Participant language was reported in four (7%) of the published texts and six (11%) when including the clinical trial registration information. Of the published texts, one (2%) reported ethnic group/race data and 40 (74%) used PROMs. Of those using PROMs, eight (20%) of 40 reported the use of translated PROMs, and three (8%) of 40 reported the use of culturally adapted PROMs.

CONCLUSIONS

There is a lack of reporting of linguistic, racial, and ethnic data and inconsistent use of PROMs, particularly those that are translated and culturally adapted, in studies included in the American Academy of Orthopaedic Surgeons CPG for distal radius fractures. As sociocultural characteristics and PROMs are associated with outcomes, ensuring they are broadly represented in studies, may improve equity and shared decision-making.

CLINICAL RELEVANCE

Greater inclusion and reporting of demographic data and PROMs are required in musculoskeletal studies to ensure broad applicability and advance health equity.

Impact of Socioeconomic Factors on Time to Surgery for Distal Radius Fractures

Background

Delay in care secondary to socioeconomic status (SES) and demographic factors represents an area for potential improvement. Reducing time to surgery in distal radius fracture (DRF) fixation may improve outcomes while reducing cost. The purpose of this study is to investigate the effect of SES on time to surgery in our study population.

Methods

Patients undergoing outpatient DRF surgery within an academic healthcare system during a 4-year period were reviewed. Time to surgery and demographic factors were analyzed. The US Census Bureau was used to determine median household income (MHI) for a patient's ZIP code; patients were stratified into three groups based on MHI.

Results

A total of 413 patients met inclusion criteria. SES (14.7 d in the low-SES group, 14.0 d in the mid-SES group, and 11.1 d in the high-SES group, P = 0.00063), insurance (11.7 d for insured versus 16.3 d for Medicaid/uninsured, P < 0.0001), race (non-White group: 15.2 d versus White group: 10.9 d, P < 0.0001), and treatment facility (16.2 d at county hospital versus 10.9 d at university hospital, P < 0.0001) were associated with time to surgery in univariate analysis. Multivariate analysis found that only treatment facility was associated with time to surgery.

Conclusions

Non-White, uninsured/Medicaid individuals residing in low-SES areas may be more likely to receive care at a safety-net facility and are at greatest risk for delay in time to surgery. Measures aimed to reduce barriers to care, increase healthcare coverage, and improve patient education should be initiated to mitigate these disparities.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment

Purpose

Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated.

Methods

This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex.

Results

In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level.

Conclusions

High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment.

Type of Study/Level of Evidence

Therapeutic III.

Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage?

BACKGROUND

While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs.

METHODS

We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05.

RESULTS

There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage.

CONCLUSIONS

Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care.

LEVEL OF EVIDENCE

Level III.

The impact of deprivation on patients awaiting planned care

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Methods

Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’.

Results

The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas.

Conclusion

The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived.

Cite this article: Bone Jt Open 2022;3(10):777–785.

Radiocarpal joint stiffness following surgical treatment for distal radius fractures: the incidence and associated factors

Background

Postoperative radiocarpal joint stiffness (RJS) is common in patients with distal radius fractures (DRFs). The purpose of this study was to record the incidence of RJS and to determine potential risk factors that may be associated with it.

Methods

We retrospectively included a series of patients who suffered from DRFs and underwent volar plate fixation. Patients’ basic data, radiographic data, and postoperative data were collected. The incidence of RJS during follow-up was recorded, and both univariate analyses and multivariate logistic regression were used to determine factors associated with it.

Results

A total of 119 patients were included in this study. After surgical procedures, there were 42 (35.3%) patients with RJS and 77 (64.7%) patients without. The incidence of RJS after surgical treatment is 35.3%. Multivariate analysis showed that intra-articular fracture (OR, 1.43; 95% CI, 1.13–1.81), pre-operative severe swelling (OR, 1.35; 95% CI, 1.05–1.74), post-operative unsatisfied volar tile (OR, 1.38; 95% CI, 1.01–1.89), and improper rehabilitation exercise (OR, 1.72; 95% CI, 1.18–2.51) were correlated with the incidence of RJS during follow-up.

Conclusions

Patients with intra-articular fracture, pre-operative severe swelling, post-operative unsatisfied volar tile, and improper rehabilitation exercise were factors associated with the incidence of wrist stiffness. Preoperative risk notification and postoperative precautions are necessary for relevant patients.

Periprosthetic atypical femoral fractures exist and are associated with duration of bisphosphonate therapy

Aims

Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment.

Patients and Methods

This was a retrospective case control study of consecutive patients with periprosthetic femoral fractures between 2007 and 2017. Two observers identified 16 PAFF cases (mean age 73.9 years (44 to 88), 14 female patients) and 17 typical periprosthetic fractures in patients on bisphosphonate therapy as controls (mean age 80.7 years (60 to 86, 13 female patients). Univariate and multivariate analysis was performed to identify predictors of PAFF. Management and complications were recorded.

Results

Interobserver agreement for the PAFF classification was excellent (kappa = 0.944; p < 0.001). On univariate analysis compared with controls, patients with PAFFs had higher mean body mass indices (28.6 kg/m2 (sd 8.9) vs 21.5 kg/m2 (sd 3.3); p = 0.009), longer durations of bisphosphonate therapy (median 5.5 years (IQR 3.2 to 10.6) vs 2.4 years (IQR 1.0 to 6.4); p = 0.04), and were less likely to be on alendronate (50% vs 94%; p = 0.02) with an indication of secondary osteoporosis (19% vs 0%; p = 0.049). Duration of bisphosphonate therapy was an independent predictor of PAFF on multivariate analysis (R2 = 0.733; p = 0.05). Following primary fracture management, complication rates were higher in PAFFs (9/16, 56%) than controls (5/17, 29%; p = 0.178) with a relative risk of any complication following PAFF of 1.71 (95% confidence interval (CI) 0.77 to 3.8) and of reoperation 2.56 (95% CI 1.3 to 5.2).

Conclusion

AFFs do occur in association with prostheses. Longer duration of bisphosphonate therapy is an independent predictor of PAFF. Complication rates are higher following PAFFs compared with typical PFFs, particularly of reoperation and infection. Cite this article: Bone Joint J 2019;101-B:1285–1291