Are we throwing the baby out with the bath water?

Mesh-based inguinal hernia repairs in an integrated healthcare system and surgeon and hospital volume: a cohort study of 110,808 patients from over a decade

PURPOSE

The aim of this study was to describe a cohort of patients who underwent inguinal hernia repair within a United States-based integrated healthcare system (IHS) and evaluate the risk for postoperative events by surgeon and hospital volume within each surgical approach, open, laparoscopic, and robotic.

METHODS

Patients aged ≥ 18 years who underwent their first inguinal hernia repair were identified for a cohort study (2010-2020). Average annual surgeon and hospital volume were broken into quartiles with the lowest volume quartile as the reference group. Multiple Cox regression evaluated risk for ipsilateral reoperation following repair by volume. All analyses were stratified by surgical approach (open, laparoscopic, and robotic).

RESULTS

110,808 patients underwent 131,629 inguinal hernia repairs during the study years; procedures were performed by 897 surgeons at 36 hospitals. Most repairs were open (65.4%), followed by laparoscopic (33.5%) and robotic (1.1%). Reoperation rates at 5 and 10 years of follow-up were 2.4% and 3.4%, respectively; rates were similar across surgical groups. In adjusted analysis, surgeons with higher laparoscopic volumes had a lower reoperation risk (27-46 average annual repairs: hazard ratio [HR] = 0.63, 95% confidence interval [CI] 0.53-0.74; ≥ 47 repairs: HR 0.53, 95% CI 0.44-0.64) compared to those in the lowest volume quartile (< 14 average annual repairs). No differences in reoperation rates were observed in reference to surgeon or hospital volume following open or robotic inguinal hernia repair.

CONCLUSION

High-volume surgeons may reduce reoperation risk following laparoscopic inguinal hernia repair. We hope to better identify additional risk factors for inguinal hernia repair complications and improve patient outcomes with future studies.

Risk of Aseptic Revision and Periprosthetic Fracture Following Bipolar Versus Unipolar Hemiarthroplasty

Hemiarthroplasty is currently the most common treatment for displaced femoral neck fractures in the elderly. While bipolar hemiarthroplasty was developed to reduce the risk of acetabular erosion that is associated with traditional unipolar hemiarthroplasty, meta-analyses have reported similar outcomes for bipolar and unipolar hemiarthroplasty devices. The primary objective of this study was to evaluate the risks of aseptic revision and periprosthetic fracture following bipolar versus unipolar hemiarthroplasty in a large integrated health-care system in the United States.

Methods

We conducted a retrospective cohort study using data from the hip fracture registry of an integrated health-care system. Patients aged ≥60 years who underwent hemiarthroplasty for hip fracture between 2009 and 2019 were included. The primary outcome measure was aseptic revision, and the secondary outcome measure was revision for periprosthetic fracture. Cause-specific Cox proportional hazards regression was performed, with mortality considered as a competing event. In the multivariable analysis, estimates were adjusted for potential confounders such as age, sex, race/ethnicity, body mass index, American Society of Anesthesiologists classification, femoral fixation, surgeon volume, type of anesthesia, and discharge disposition.

Results

The study sample included 13,939 patients who had been treated with hemiarthroplasty by 498 surgeons at 35 hospitals. The mean follow-up time was 3.7 ± 2.9 years. The overall incidence of aseptic revision at 5 years following hemiarthroplasty was 2.8% (386). In the multivariable analysis controlling for potential confounders, bipolar hemiarthroplasty was associated with a lower risk of aseptic revision than unipolar hemiarthroplasty (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.59 to 0.94; p = 0.012). Rates of revision for periprosthetic fracture were similar between the bipolar and unipolar devices (HR, 0.79; 95% CI, 0.58 to 1.10; p = 0.16).

Conclusions

In this study of hemiarthroplasty for hip fracture in elderly patients, bipolar designs were associated with a lower risk of aseptic revision than unipolar designs. In contrast to prior research, we did not find any difference in the risk of periprosthetic fracture between the 2 designs.

Level of Evidence

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

The association between critical shoulder angle and revision following anatomic total shoulder arthroplasty: a matched case-control study

HYPOTHESIS

The concept of the critical shoulder angle (CSA) was introduced in 2013, with studies showing that larger CSA is associated with rotator cuff tears (RCTs) and smaller CSA with glenohumeral osteoarthritis. We hypothesized outcomes following total shoulder arthroplasty (TSA) would differ depending on CSA.

METHODS

We conducted a matched case-control study using Kaiser Permanente's Shoulder Arthroplasty Registry to identify patients who underwent primary elective anatomic TSA for the diagnosis of osteoarthritis from 2009-2018. Seventy-eight adult patients who underwent revision following the primary TSA due to glenoid component failure or rotator cuff tear comprised the case group. A control group of nonrevised patients were identified from the same source population. Two controls were matched to each case by age, gender, body mass index, American Society of Anesthesiologists classification, surgeon who performed the index TSA, and post-TSA follow-up time. The relationship between revision and CSA as measured on radiographs were analyzed as a 1:2 matched-pairs case-control study with use of multiple conditional multivariable logistic regression.

RESULTS

Revised cases had a higher likelihood of a CSA ≥35° (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.27-4.59). A higher likelihood of CSA ≥35° was observed for those revised for glenoid loosening (OR = 4.58, 95% CI = 1.20-17.50) and revised for rotator cuff tear (OR = 2.41, 95% CI = 1.18-4.92) compared with nonrevised controls. Every 5° increase in CSA had higher odds of overall revision (OR = 1.62, 95% CI = 1.18-2.21), glenoid loosening (OR = 2.50, 95% CI = 1.27-4.92), and rotator cuff tear (OR = 1.51, 95% CI = 1.07-2.14).

CONCLUSION

In a matched case-control study of primary anatomic TSA, individuals who were revised for aseptic glenoid loosening and superior cuff failure had a higher CSA compared with nonrevised individuals. These data suggest that surgeons may consider using reverse arthroplasty in cases of primary shoulder arthritis with a CSA of 35° or greater.

Association Between the Femoral Stem Design Type and the Risk of Aseptic Revision After Hemiarthroplasty

INTRODUCTION

Although noncemented hemiarthroplasty has been associated with a higher risk of revision surgery as compared with cemented fixation, it remains uncertain whether this increased risk applies to all noncemented stem design types or only a subset. The purpose of this study was to assess the risk of aseptic revision associated with three common types of noncemented stem designs as compared with cemented fixation in the hemiarthroplasty treatment of femoral neck fractures in the elderly patients.

METHODS

This was a retrospective cohort study of patients aged 60 years and older who sustained a hip fracture and underwent hemiarthroplasty between 2009 and 2018 at one of 35 hospitals owned by a large US health maintenance organization. Hemiarthroplasty fixation was categorized as cemented or noncemented, with the noncemented stems further classified as single wedge without collar, fit and fill without collar, or fit and fill with collar. The primary outcome was aseptic revision, and the median follow-up time was 4.8 years.

RESULTS

Of 12,071 patients who underwent hemiarthroplasty during the study period (average age 82.0 ± 8.4 years, 67.9% women), 807 (6.7%) received a single-wedge stem without collar, 2,124 (17.6%) received a fit-and-fill stem without collar, 2,453 (20.3%) received a fit-and-fill stem with collar, and 6,687 (55.4%) received a cemented stem. Compared with cemented fixation, all the noncemented stem design types were associated with a markedly higher risk of aseptic revision in the multivariable analysis, including single wedge without collar (hazard ratio [HR] 2.00, 95% confidence interval [CI], 1.38 to 2.89, P < 0.001), fit and fill without collar (HR 1.52, 95% CI, 1.14 to 2.04, P = 0.005), and fit and fill with collar (HR 2.11, 95% CI, 1.63 to 2.72, P < 0.001).

CONCLUSION

In the hemiarthroplasty treatment of elderly patients with hip fracture, all routinely used noncemented stem design types were associated with a higher risk of aseptic revision as compared with cemented fixation.

Early revision in anatomic total shoulder arthroplasty in osteoarthritis: a cross-registry comparison

BACKGROUND

We evaluated anatomic total shoulders undergoing early revision (less than two years) in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Kaiser Permanente Shoulder Arthroplasty Registry (KPSAR).

METHODS

A cross-sectional comparison of both registries was performed between the years of 2009 and 2012. Only patients who underwent anatomic total shoulder arthroplasty for a primary diagnosis of osteoarthritis were included. Aggregate-level data of patients undergoing early revisions done within two years of index arthroplasty were evaluated, and descriptive analysis was conducted.

RESULTS

During the study period, 4614 patients were identified in the AOANJRR compared to 2036 in the KPSAR. Rotator cuff pathology, component loosening, and prosthetic instability were among the most common reasons for revision in both registries. A higher rate of revision in the AOANJRR was found to be secondary to the failure of one specific prosthesis, which has since been discontinued.

DISCUSSION

Comparing reasons for early revision in total shoulder arthroplasty revealed several similarities between the AOANJRR and KPSAR. Differences were also noted, and this study served to highlight the importance prosthesis selection can play in determining outcomes. Cooperation among registries may allow for earlier identification of risk factors for failure in shoulder arthroplasty.

Risk Factors for Re-Revision Surgery in Shoulder Arthroplasty

INTRODUCTION

Revision shoulder arthroplasty is an expensive undertaking with notable morbidity to the patient and less predictable outcomes. Therefore, it is important to avoid even further surgery in these patients. We sought to report the annual revision burden from a large integrated healthcare system and identify patient and operative factors that may predispose patients to revision failure, necessitating further surgery.

METHODS

Annual revision burden as a proportion of the overall shoulder arthroplasties performed from 2005 to 2017 was obtained. Patients who underwent aseptic revision between 2005 and 2017 comprised the study sample. Patient characteristics evaluated for re-revision risk included age, sex, body mass index (BMI), race, and diabetes status, whereas surgical characteristics included surgeon cumulative revision volume, revision procedure type, and top reason for revision by primary procedure type. Multivariable Cox proportional hazards regression was used to evaluate the association between the specified factors and re-revision risk.

RESULTS

From 2005 to 2017, revisions represented 5.3% to 7.8% of all shoulder arthroplasty procedures performed. Factors associated with re-revision surgery risk by procedure type included increasing BMI and hemiarthroplasty revision procedure compared with reverse total shoulder arthroplasty (RTSA) revision procedure for hemiarthroplasty primaries; diabetes, revision because of instability, and lower cumulative surgeon revision procedure volume for RTSA primaries; and TSA revision procedure compared with RTSA revision procedure for TSA primaries.

CONCLUSION

The annual revision shoulder arthroplasty volume increased over the study period. Patient factors, including BMI and diabetes were associated with higher re-revision risks for hemiarthroplasty and RTSA primaries, respectively. RTSA revised for instability had a higher risk of re-revision compared with other indications. TSA and hemiarthroplasty requiring aseptic revision may be best treated with RTSA as opposed to another TSA or hemiarthroplasty. Further studies are needed to verify these findings and identify how the mechanism of failure may affect the procedure selection in the revision setting.

LEVEL OF EVIDENCE

Level III.

The association between glenoid component design and revision risk in anatomic total shoulder arthroplasty

INTRODUCTION

Anatomic total shoulder arthroplasty (TSA) is a proven treatment for glenohumeral joint osteoarthritis, with superior results compared with hemiarthroplasty. However, glenoid component loosening remains a problem and is one of the most common causes of failure in TSA. Multiple component designs have been developed in an attempt to reduce loosening rates. The purpose of this study was to evaluate risk of revision after anatomic TSA according to the glenoid component design.

METHODS

We conducted a cohort study including patients aged ≥18 years who underwent primary elective TSA for the diagnosis of osteoarthritis between 2010 and 2017. Patients with missing implant information, who received stemless humeral implants, or who received augmented glenoid implants, were excluded. Glenoid component designs used were categorized into 4 mutually exclusive treatment groups: polyethylene central-pegged ingrowth, polyethylene-metal hybrid, polyethylene all-cemented pegged, and polyethylene cemented keeled. Multivariable competing risk regression was used to evaluate the risk of glenoid loosening as a cause-specific revision by the glenoid component design.

RESULTS

Of the 5566 TSA included in the final cohort, 39.2% of glenoid implants were polyethylene central-pegged ingrowth, 31.1% were polyethylene-metal hybrid, 26.0% were polyethylene all-cemented pegged, and 3.6% were polyethylene cemented keeled. At 6-year final follow-up, 4.1% of TSA were revised for any cause, and 1.4% for glenoid loosening. Compared with the polyethylene central-pegged ingrowth design, no difference in glenoid loosening revision risk was observed for the polyethylene-metal hybrid design (hazard ratio [HR] = 1.15, 95% confidence interval [CI] = 0.42-3.20). However, both the polyethylene all-cemented pegged (HR = 2.48, 95% CI = 1.08-5.66) and polyethylene cemented keeled (HR = 3.84, 95% CI = 1.13-13.00) designs had higher risks for revision due to glenoid loosening.

CONCLUSIONS

We observed glenoid component designs to be associated with differential risks in revision due to glenoid loosening with polyethylene all-cemented pegged glenoids and polyethylene cemented keeled glenoids having higher risks when compared with polyethylene central-pegged ingrowth glenoids. Surgeons may want to consider the glenoid component design when performing anatomic TSA.

The association between race/ethnicity and outcomes following primary shoulder arthroplasty

BACKGROUND

Although prior studies have reported health disparities in total knee and hip arthroplasty, few have evaluated the effect of race/ethnicity on total shoulder arthroplasty, particularly in a setting in which patients have uniform access to care. Because the procedural volume of shoulder arthroplasty has increased dramatically over the past decade, evaluating the association between race/ethnicity and postoperative outcomes is warranted. We sought to evaluate racial/ethnic disparities in adverse postoperative events within a universally insured shoulder arthroplasty cohort in an integrated health care system.

METHODS

An integrated health care system's registry was used to identify patients who underwent elective primary (total or reverse) shoulder arthroplasty from 2005 to 2016. Four mutually exclusive race/ethnicity groups were investigated: white, Asian, black, and Hispanic. Racial differences were evaluated using Cox proportional hazards regression for all-cause revision and conditional logistic regression for 90-day unplanned readmissions and 90-day emergency department (ED) visits while adjusting for confounders.

RESULTS

Of the 8360 shoulder procedures, 2% were performed in Asian patients; 5%, black patients; 9%, Hispanic patients; and 84%, white patients. Compared with white patients, Hispanic patients had a 44% lower revision risk (hazard ratio, 0.56; 95% confidence interval, 0.33-0.97). Black patients had a 45% higher likelihood of a 90-day ED visit (odds ratio, 1.45; 95% confidence interval, 1.12-1.89).

CONCLUSION

We found minority groups to have revision and unplanned readmission risks that were similar to or lower than those of white patients. However, black patients had a higher likelihood of ED visits. Further investigation is needed to determine the reasons for this disparity and identify interventions to mitigate unnecessary ED visits.

Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture

IMPORTANCE

Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience.

OBJECTIVE

To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017.

EXPOSURES

Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions.

RESULTS

Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08).

CONCLUSIONS AND RELEVANCE

Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.

Core set of unfavorable events of shoulder arthroplasty: an international Delphi consensus process

BACKGROUND

Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.

METHODS

A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.

RESULTS

Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).

CONCLUSION

A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population

BACKGROUND

Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system.

METHODS

A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders.

RESULTS

Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients.

CONCLUSIONS

In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty has a higher risk of revision due to infection than anatomical shoulder arthroplasty

Aims

The aim of this study was to use national registry database information to estimate cumulative rates and relative risk of revision due to infection after reverse shoulder arthroplasty.

Patients and Methods

We included 17 730 primary shoulder arthroplasties recorded between 2004 and 2013 in The Nordic Arthroplasty Register Association (NARA) data set. With the Kaplan–Meier method, we illustrated the ten-year cumulative rates of revision due to infection and with the Cox regression model, we reported the hazard ratios as a measure of the relative risk of revision due to infection.

Results

In all, 188 revisions were reported due to infection during a mean follow-up of three years and nine months. The ten-year cumulative rate of revision due to infection was 1.4% overall, but 3.1% for reverse shoulder arthroplasties and 8.0% for reverse shoulder arthroplasties in men. Reverse shoulder arthroplasties were associated with an increased risk of revision due to infection also when adjusted for sex, age, primary diagnosis, and year of surgery (relative risk 2.41 (95% confidence interval 1.26 to 5.59); p = 0.001).

Conclusion

The overall incidence of revision due to infection was low. The increased risk in reverse shoulder arthroplasty must be borne in mind, especially when offering it to men. Cite this article: Bone Joint J 2019;101-B:702–707.

The increasing role of reverse total shoulder arthroplasty in the treatment of proximal humerus fractures

INTRODUCTION

Hemiarthroplasty of the shoulder is a well established treatment for proximal humerus fractures not amenable to open reduction internal fixation. However, orthopedic surgeons have recently increased utilization of reverse total shoulder arthroplasty (RTSA) in the treatment of these injuries. The purpose of this study was to evaluate the use of hemiarthroplasty and RTSA between 2009 and 2016 for the treatment of proximal humerus fractures within a large United States integrated healthcare system.

MATERIALS AND METHODS

A descriptive study was conducted using our integrated healthcare system's Shoulder Arthroplasty Registry. Shoulder arthroplasty cases performed for an acute proximal humerus fracture between the years of 2009 and 2016 were identified. Revision rates were determined, as well as changes in age and gender distribution of the cohort during the study period.

RESULTS

In 2015, RTSA utilization surpassed that of hemiarthroplasty for the first time in the healthcare system. The utilization of RTSA in the treatment of proximal humerus fractures increased from 4.5% of all arthroplasties in 2009 to 67.4% of arthroplasties in 2016. During the study period, patients undergoing hemiarthroplasty were younger and less likely to be female. Crude revision rate was 4.0% for hemiarthroplasty and 3.2% for RTSA.

CONCLUSIONS

RTSA is increasingly being utilized for the treatment of proximal humerus fractures and now appears to be the treatment of choice. While hemiarthroplasty appears to be falling out of favor in the treatment of fractures of the shoulder, surgeons may still be preferentially using the procedure in younger patients.

Association Between Race and Ethnicity and Hip Fracture Outcomes in a Universally Insured Population

BACKGROUND

Prior studies have documented racial and ethnic disparities in hip fracture treatment and outcome, and unequal access is commonly cited as a potential mediator. We sought to assess whether disparities in hip fracture outcome persist within a universally insured population of patients enrolled in a managed health-care system.

METHODS

A U.S. integrated health systems registry was used to identify patients who underwent treatment for a hip fracture when they were ≥60 years of age from 2009 to 2014. Patient demographics, procedure details, and outcomes were obtained from the registry. Differences in outcome according to race/ethnicity were analyzed using multivariable regression analysis with adjustment for socioeconomic status and other potential confounders.

RESULTS

Of 17,790 patients, 79.4% were white, 3.9% were black, 9.4% were Hispanic, and 7.4% were Asian. Compared with white patients, black patients had a similar 1-year mortality rate (odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.79 to 1.09, p = 0.37), Hispanic patients had a lower rate (OR = 0.85, 95% = CI = 0.75 to 0.96, p = 0.01), and Asian patients also had a lower rate (OR = 0.65, 95% CI = 0.56 to 0.76, p < 0.001). There were no differences in terms of surgical delay, 90-day emergency department visits, or reoperations during the patient's lifetime (p > 0.05) between the groups. Compared with white patients, black and Hispanic patients had fewer 90-day postoperative complications (p = 0.04 and p = 0.01, respectively); 90-day unplanned readmissions were less common among Asian patients (p = 0.03) but more common among black patients (p = 0.01).

CONCLUSIONS

In this study of hip fractures treated in an integrated managed care system, minority patients were found to have postoperative mortality rates that were similar to, or lower than, those of white patients. These findings may be related to the equal access and/or standardized protocols associated with treatment in this managed care system.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.