Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 to 2015

Association of Geographic Social Vulnerability With Race-Based Differences in the Utilization of Total Hip Arthroplasty Surgeries for Medicare Beneficiaries

BACKGROUND

Racial disparities exist in the utilization of total hip arthroplasties (THAs). The social vulnerability index (SVI), which measures geographic-level disadvantage and includes themes, such as socioeconomic status, minority status, and language, may partially explain disparities in THA use. Our objectives were to determine the association of the composite SVI with THA use for (1) White Medicare beneficiaries, (2) Black Medicare beneficiaries, and (3) the difference in THA use between White and Black beneficiaries. We also determined the association of SVI themes with these THA-use endpoints.

METHODS

We used 2013 to 2019 Medicare data to calculate age- and sex-standardized THA use rates for 306 hospital referral regions (HRRs). We estimated multivariable linear regression models to determine the association of the composite SVI and its four themes with THA utilization and with differences in use rates.

RESULTS

Living in HRRs with the highest SVI (most vulnerable, quartile 4) was associated with lower hip arthroplasty rates for both White and Black beneficiaries (e.g., quartile 4 for White beneficiaries: -0.9, 95% confidence interval [95% CI]: -1.2 to -0.7, P < 0.001; quartile 4 for Black beneficiaries: -0.9, 95% CI: -1.3 to -0.5, P < 0.001) compared to beneficiaries in the least vulnerable HRRs (quartile 1). Higher vulnerability in minority status and language (theme 3) was associated with lower THA utilization for Black beneficiaries only (e.g., quartile 4 for Black beneficiaries: -0.9, 95% CI: -1.2 to -0.5, P < 0.001) and was associated with widening of the White-Black difference in THA utilization (e.g., quartile 4: 0.7, 95% CI: 0.3 to 1.1, P < 0.001).

CONCLUSIONS

Higher composite SVI is associated with lower THA utilization for both White and Black beneficiaries. Higher vulnerability in minority status and language is associated with the widening of the disparity in THA rates. Our findings highlight important mechanisms that need to be addressed to ensure equity in THA access.

Patient-Physician Racial Concordance Increases Likelihood of Total Knee Arthroplasty Recommendation

BACKGROUND

Minority patients have been shown to underutilize total knee arthroplasty (TKA) compared to non-Hispanic White patients. Specific drivers of this underutilization have not been identified. We sought to determine if racial concordance between patient and physician is associated with the surgeon's likelihood to recommend TKA.

METHODS

There were 402 patients who presented for management of knee osteoarthritis to the clinics of four fellowship-trained arthroplasty surgeons at a single academic center. We recorded the patient and surgeon's race/ethnicity as well as the physician-recommended treatment. Patient clinical data was input to the American Academy of Orthopaedic Surgeons (AAOS) appropriate use criteria website to generate a guideline-based procedure recommendation for TKA. Patients who were not appropriate for TKA based on AAOS guidelines were excluded from analyses to minimize selection bias. Chi-square and multivariable regression analyses evaluated the relationship between TKA recommendation by surgeon and physician-patient racial concordance.

RESULTS

Patients in this cohort who experienced racial concordance with their surgeon were more likely to receive a recommendation for TKA than patients who experienced racial discordance. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1 versus 23.0%, P = 0.0001). The same effect was not observed in non-Hispanic White patients, where there was no significant difference in surgery offers between patients who received concordant versus discordant care (P = 0.18). Multivariable analyses were also conducted to test factors associated with TKA recommendations. Racial concordance was found to be an independent predictor of TKA recommendation while controlling for patient factors and individual differences by the surgeon.

CONCLUSIONS

Patients receiving racially concordant care in this cohort were more likely to be offered TKA, and the effect of racial concordance on TKA recommendation was greater among Black patients. These findings provide insight into possible drivers of TKA underutilization among minority groups.

Racial and Ethnic Disparities in Predictive Accuracy of Machine Learning Algorithms Developed Using a National Database for 30-Day Complications Following Total Joint Arthroplasty

BACKGROUND

While predictive capabilities of machine learning (ML) algorithms for hip and knee total joint arthroplasty (TJA) have been demonstrated in previous studies, their performance in racial and ethnic minority patients has not been investigated. This study aimed to assess the performance of ML algorithms in predicting 30-days complications following TJA in racial and ethnic minority patients.

METHODS

A total of 267,194 patients undergoing primary TJA between 2013 and 2020 were identified from a national outcomes database. The patient cohort was stratified according to race, with further substratification into Hispanic or non-Hispanic ethnicity. There were two ML algorithms, histogram-based gradient boosting (HGB), and random forest (RF), that were modeled to predict 30-days complications following primary TJA in the overall population. They were subsequently assessed in each racial and ethnic subcohort using discrimination, calibration, accuracy, and potential clinical usefulness.

RESULTS

Both models achieved excellent (Area under the curve (AUC) > 0.8) discrimination (AUCHGB = AUCRF = 0.86), calibration, and accuracy (HGB: slope = 1.00, intercept = -0.03, Brier score = 0.12; RF: slope = 0.97, intercept = 0.02, Brier score = 0.12) in the non-Hispanic White population (N = 224,073). Discrimination decreased in the White Hispanic (N = 10,429; AUC = 0.75 to 0.76), Black (N = 25,116; AUC = 0.77), Black Hispanic (N = 240; AUC = 0.78), Asian non-Hispanic (N = 4,809; AUC = 0.78 to 0.79), and overall (N = 267,194; AUC = 0.75 to 0.76) cohorts, but remained well-calibrated. We noted the poorest model discrimination (N = 1,870; AUC = 0.67 to 0.68) and calibration in the American-Indian cohort.

CONCLUSIONS

The ML algorithms demonstrate an inferior predictive ability for 30-days complications following primary TJA in racial and ethnic minorities when trained on existing healthcare big data. This may be attributed to the disproportionate underrepresentation of minority groups within these databases, as demonstrated by the smaller sample sizes available to train the ML models. The ML models developed using smaller datasets (e.g., in racial and ethnic minorities) may not be as accurate as larger datasets, highlighting the need for equity-conscious model development.

LEVEL OF EVIDENCE

III; retrospective cohort study.

A Higher Area Deprivation Index Is Associated With Increased Medical Complications and Emergency Department Utilizations After Total Hip Arthroplasty

BACKGROUND

The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. The purpose of this study was to determine whether patients undergoing total hip arthroplasty (THA) in areas of high ADI (greater disadvantage) were associated with differences in 90 days: 1) medical complications; 2) emergency department (ED) utilizations; and 3) readmissions.

METHODS

A nationwide database was queried for primary THA patients from 2010 to 2020. The ADI is reported on a scale of 0 to 100, with higher numbers indicating greater disadvantage. Patients undergoing primary THA in regions associated with high ADI (90%+) were compared to those of lower ADI (0 to 89%). A total of 138,670 patients were evenly matched between the two cohorts following 1:1 propensity score matching by age, sex, and Elixhauser Comorbidity Index. Primary endpoints were 90-day medical complications, ED utilizations, and readmissions. Multivariable logistic regression models calculated the odds ratios (ORs) and 95% confidence intervals (CIs). P values less than 0.01 were statistically significant.

RESULTS

Patients undergoing THA from high ADI had significantly higher rates and odds of developing any medical complications (13.0 versus 11.9%; OR: 1.09, P < 0.0001), including acute kidney injuries (1.8 versus 1.5%; OR: 1.20, P < 0.0001), myocardial infarctions (0.35 versus 0.24%; OR: 1.45, P = 0.0003), and surgical site infections (0.94 versus 0.76%; OR: 1.23, P = 0.0004). High-ADI patients had significantly higher rates and odds of ED visits within 90 days (3.94 versus 3.67%; OR: 1.08, P = 0.008). There was no significant difference in readmissions (5.44 versus 5.69%; OR: 0.95, P = 0.034).

CONCLUSIONS

Socioeconomically disadvantaged patients have increased odds of 90-days medical complications and ED utilizations, despite comparable 90-day readmission rates. Measures of neighborhood disadvantage may be valuable metrics to inform health care policy and improve postdischarge care.

Effect of Race and Socioeconomic Status on the Attainment of Substantial Clinical Benefit on Patient-Reported Outcome Measures Following Total Joint Arthroplasty

BACKGROUND

Utilization of and access to total joint arthroplasty (TJA) are disproportionately skewed in patients who have low socioeconomic status (SES) and in minority populations. Patient-reported outcome measures (PROMs) are critical markers of post-surgical outcomes following TJA. This study aimed to: 1) evaluate differences in race, SES, and demographic factors between TJA patients who achieved substantial clinical benefit (SCB) and those who did not; 2) assess differences between preoperative PROMs in these patients; and 3) identify whether race and SES are associated with SCB achievement at 1-year post-TJA.

METHODS

This retrospective cohort study included 1,154 total hip arthroplasty (THA) and 1,879 total knee arthroplasty (TKA) patients who underwent surgery at a single academic medical center from May 2019 to February 2023. Preoperative and postoperative PROMs were collected using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement surveys. Demographic and comorbidity data were collected from charts. Multivariable logistic regression analyzed the association between predictive variables and SCB achievement.

RESULTS

No differences in race were found between patients who achieved SCB and those who did not for both TKA and THA (P > 0.05). However, preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores were lower in Black (P = 0.004) and Hispanic (P < 0.001) patients and preoperative Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores were lower in Black patients (P < 0.001) than White patients. A higher proportion of patients in the lowest income category achieved SCB for both THA and TKA than those in other income categories (P = 0.04, P = 0.03, respectively). However, race was not associated with SCB likelihood at one year. For TKA patients, men were negative, and bilateral simultaneous TKA was positively associated with SCB achievement when controlling for race, income, and body mass index (P < 0.001, P = 0.01, respectively).

CONCLUSIONS

Race and income category were not significantly associated with achieving SCB at one year among TJA patients. However, non-White patients had a similar likelihood of achieving SCB as White patients, even with lower preoperative PROMs, indicating that these patients may benefit greatly from TJA despite delays in care. Men were negatively associated with TKA SCB achievement, while bilateral simultaneous TKA was positively associated with SCB.

Disparities in Utilization Rates of Total Knee and Hip Arthroplasty Among Racially Visible Populations in Canada: A Retrospective Cohort Analysis

BACKGROUND

Published evidence on total hip arthroplasty (THA) and knee arthroplasty (TKA) among racially visible (RV) populations suggests inequities in utilization rates. The study's aim was to compare THA and TKA utilization rates in RV populations to the general population (non-RV). Additionally, we compared rates in populations of African descent (AD) to non-African descent (non-AD) population.

METHODS

The study population was identified from the 2016 Canadian long-form census, and minority status was self-reported. Statistics Canada and Canadian Institute of Health Information used personal information from multiple sources to construct a unique identifier, enabling accurate linkage across data sources. Census data captured key covariates including age, sex, and income. Procedures of THA and TKA were identified from the Discharge Abstract Database and National Ambulatory Care Reporting System. Multivariate logistic regression was employed in comparing utilization rates between groups, controlling for confounders including age, sex, and income. Chi-square statistics were used to test for statistically significant differences at a 95% confidence level.

RESULTS

The observed utilization rates for TKA and THA were lower for RVs and ADs compared to non-RV and non-AD populations, respectively. Multivariate analyses revealed an adjusted odds ratio (OR) of RV individuals undergoing THA of 0.22 (P < 0.001) compared to non-RV individuals, with a lower probability for RVs. Similarly, RV individuals had a statistically lower probability of undergoing TKA compared to non-RV individuals (OR 0.72, P < 0.001). The probability of AD individuals undergoing THA (OR 0.46, P < 0.001) and TKA (OR 0.73, P < 0.0001) after adjusting for confounders was lower compared to non-AD populations.

CONCLUSIONS

Disparities in THA and TKA utilization rates were pervasive among racialized populations across Canada. We advocate that future studies on access to investigate causality or potential factors driving the observed disparity, such as language barriers and sociocultural perceptions regarding surgery.

LEVEL OF EVIDENCE

III.

Socioeconomic Deprivation Influences Failure to Attend Arranged Orthopaedic Outpatient Appointments as Well as Access to and Engagement With Health Care: A Cohort Study

Background

We undertook this study to examine the "did-not-attend" (DNA) rate for the orthopaedic outpatient clinic at a large tertiary center, to understand the influencing factors and reasons from the patient perspective and to determine the impact of socioeconomic deprivation.

Methods

We reviewed all scheduled outpatient attendances to our trauma and orthopaedic surgery service over a 12-month period and demographic information for each patient, including the Index of Multiple Deprivation. We studied the rate and predictors for nonattendance in the outpatient clinic and the influence of socioeconomic deprivation. We undertook a secondary study to evaluate the reasons patients gave for nonattendance, their perception of the accessibility, usefulness, and format of the outpatient model and any relationship with socioeconomic deprivation.

Results

Eighteen thousand thirty-three patients attended 58,396 outpatient appointments over the 12-month study period. 2060 patients "did not attend" at least one arranged orthopaedic outpatient appointment over the 12 months of the study period. Men and more socioeconomically deprived patients were more likely to not attend. The most common reasons given for not attending were that patients did not feel that the appointment was useful for them. Patients from socioeconomically deprived groups were more likely to reference transport difficulties as a reason for not attending (p < 0.001). Socioeconomically deprived and disadvantaged patients reported poorer satisfaction scores regarding how able they felt to access orthopaedic help and services when they needed to and how able they felt to access orthopaedic help and services in a way that suits them.

Conclusions

Socioeconomic deprivation affects health and access to health care. Patients who are more socioeconomically deprived are more likely to not attend, and they report poorer satisfaction with access to orthopaedic outpatient care. DNA rates may reflect underlying health disparities.

Level of Evidence

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

Spine Surgery Outcomes in Patients With Limited English Proficiency

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study is to investigate the impact of language-discordant spine care. Specifically, do non-English speakers (NES) experience (1) increased length of stay? (2) increased rates of complications (ie, intra/perioperative complications, revision surgery, reoperation)?

BACKGROUND

To provide the best care, there exists a growing focus on understanding which patient groups may be at greater risk for poorer outcomes. In the current body of orthopedic and spine literature, there is little data regarding outcomes for patients where there is language discordance between the physician and patient.

PATIENTS AND METHODS

This is a retrospective cohort study. Patients who underwent spine surgery at a single institution between 2017 and 2023 were included. Translator usage was used as a proxy for poor English language proficiency. Patient demographic and outcome data were collected from the electronic medical record. Patients were matched on surgical and demographic factors and analyzed for outcome variables. Multivariable logistic regressions were run to assess variables associated with poor outcomes.

RESULTS

A total of 214 NES and 9217 English speakers (ES) were reviewed. The final matched cohort resulted in 158 NES and 313 ES with no differences in demographic data. NES patients had significantly more postoperative visits (2.19 vs 1.73; P < 0.001) and increased readmission rates (0.96% vs 4.43%; P = 0.033). On multivariable analysis, NES were predictive of readmission (OR = 4.22; P = 0.039).

CONCLUSION

Patients with low English proficiency experienced significantly higher rates of readmissions following spine surgery. These patients may benefit from increased and more effective preoperative and postoperative communication.

LEVEL OF EVIDENCE

Level IV.

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.

Do Socioeconomic Factors Affect Symptom Duration and Disease Severity at Presentation for Cubital Tunnel Syndrome?

BACKGROUND

Socioeconomic factors have been implicated in delayed presentation for compressive neuropathies of the upper extremity. Our article seeks to elucidate the effect of socioeconomic factors on self-reported symptom duration and objective disease severity at presentation for cubital tunnel syndrome.

METHODS

This retrospective cohort study included 207 patients with surgical management of cubital tunnel syndrome at 2 institutions between June 1, 2015, and March 1, 2020. Exclusion criteria included age under 18 years, revision surgery, lack of preoperative electrodiagnostic studies, and concurrent additional surgeries. Response variables were self-reported symptom duration, time from presentation to surgery, McGowan grade, and electrodiagnostic measures. Explanatory variables included age, sex, white race, diabetes mellitus, depression, anxiety, and the Distressed Communities Index.

RESULTS

Symptom duration was associated with nonwhite race, and time from presentation to surgery was associated with insurance provider. More clinically severe disease was associated with older age, male sex, and not having carpal tunnel syndrome. Nonrecordable sensory nerve action potential latency was associated with older age, higher body mass index, male sex, diabetes mellitus, and unemployment. Nonrecordable conduction velocities were associated with older age, and having fibrillations at presentation was associated with older age, male sex, and unemployment.

CONCLUSIONS

Economic distress is not associated with self-reported symptom duration, time from presentation to surgery, or presenting severity of cubital tunnel syndrome. White patients presented with shorter self-reported symptom duration. Insurance type was associated with delay from presentation to surgery. Older age and male sex were risk factors for more clinically severe disease at presentation.

Impact of Race and Social Determinants on Operative Management of Distal Radius Fractures in Medicare Patients

Background

Operative fixation of distal radius fractures (DRFs) in high-demand patients may provide functional benefit, particularly in the setting of significant displacement. Whether social determinants of health (SDOH) and race impact treatment remain unclear. The purpose of this study was to determine whether adverse SDOH modifiers and race are independent predictors of surgical intervention for DRF.

Methods

A retrospective analysis was conducted using the Medicare Standard Analytical Files of the PearlDiver database of patients with a DRF from 2007 to 2016. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOH variables were independent predictors of undergoing open reduction internal fixation (ORIF) within 3 weeks of a new diagnosis of DRF after controlling for age and fracture type.

Results

The average patient age was 76.3 years. A total of 10,697 (13.1%) patients underwent ORIF. Patients who underwent ORIF were less likely to have negative economic and social modifiers of SDOH and had lower odds of being non-White. Patients who underwent surgery also had higher odds of being younger, White, female, and having a type III open fracture.

Conclusions

In the Medicare population, non-White race and adverse economic and social modifiers of SDOH were independent predictors of undergoing nonoperative treatment of DRF after controlling for age and fracture type. Future studies are needed to further elucidate the nuanced effects of race and SDOH on the management of DRFs.

Racial disparities in osteoarthritis: Prevalence, presentation, and management in the United States

Osteoarthritis (OA) is the most common form of arthritis in the United States, affecting approximately 24 % of adults. This literature review aims to summarize racial and ethnic disparities in OA prevalence, presentation, disability, diagnosis, and management among different groups in the U.S. The review found significant disparities, particularly affecting African Americans (AAs) and Hispanics (HISs) compared to non-Hispanic whites (WHs). AAs showed higher odds of developing symptomatic and radiological knee OA, with more severe radiological features. Pain and disability due to OA were also more pronounced in AAs and HISs. Disparities extended to imaging workup, with AAs less likely to undergo hip X-rays and MRIs for hip OA. Management strategies, including physical therapy, pharmacological treatments, and surgical interventions, were less utilized by AAs and HISs compared to WHs. These disparities are influenced by complex, multifaceted factors including socioeconomic status, education level, and healthcare access. The review highlights the urgent need for targeted interventions and policy changes to address these racial-ethnic disparities in OA care and outcomes.

Racial Disparities in Total Knee and Hip Arthroplasty in a Medically Underserved Community with a Diverse Population

INTRODUCTION

Previous studies have demonstrated lower total joint arthroplasty utilization rates and worse postoperative outcomes among non-White patients. Our study examined whether these disparities exist in the setting of a diverse population.

METHODS

This retrospective study included patients with a self-reported race who underwent total knee (TKA) or hip (THA) arthroplasty procedures in a racially diverse county. Patients who did not identify as White or Hispanic/Latino were excluded from the study due to small sample sizes. Demographic, intra and postoperative outcome differences were calculated. A multivariate logistic regression was developed to examine the association between patients' race and undesired postoperative outcomes.

RESULTS

Five hundred fifty-five patients were included in our study with 490 identifying as non-Hispanic/Latino White (88.8%) and 65 as Hispanic/Latino (11.2%). Hispanic/Latino-identifying patients were significantly younger (61.9 ± 12.79 versus 68.58 ± 9.00 years), had lower Charlson Comorbidity Index scores, and were more likely to use non-Medicare/Medicaid insurance. We observed no differences between our cohorts in postoperative adverse events, emergency department visits, and hospital readmissions. Patients' self-identified race was not correlated with undesired postoperative outcomes.

CONCLUSIONS

Although Hispanic/Latino-identifying patients constitute 50.2% of the county population of our study cohort, they accounted for only 11.2% of the patients in our study. This is noteworthy considering the lack of evidence suggesting a decreased prevalence of osteoarthritis among individuals of different races and ethnicities. Further, the demographic differences we observed suggest an exclusive Hispanic/Latino patient population utilizing TKA or THA procedures. Future studies controlling for risk factors and less invasive treatment options may explain these disparities.

Socioeconomic Status Impacts Length of Stay and Nonhome Discharge Disposition After Posterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To examine how community-level economic disadvantage impacts short-term outcomes following posterior cervical decompression and fusion (PCDF) for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

The effects of socioeconomic factors, measured by the Distress Community Index (DCI), on postoperative outcomes after PCDF are underexplored. By understanding the impact of socioeconomic status (SES) on PCDF outcomes, disparities in care can be addressed.

MATERIALS AND METHODS

Retrospective review of 554 patients who underwent PCDF for cervical spondylotic myelopathy between 2017 and 2022. SES was assessed using DCI obtained from patient zip codes. Patients were stratified into quintiles from Prosperous to Distressed based on DCI. Bivariate analyses and multivariate regressions were performed to evaluate the associations between social determinants of health and surgical outcomes, including length of stay, home discharge, complications, and readmissions.

RESULTS

Patients living in at-risk/distressed communities were more likely to be Black (53.3%). Patients living in at-risk/distressed communities had the longest hospitalization (6.24 d vs. prosperous: 3.92, P =0.006). Significantly less at-risk/distressed patients were discharged home without additional services (37.3% vs. mid-tier: 52.5% vs. comfortable: 53.4% vs. prosperous: 56.4%, P <0.001). On multivariate analysis, residing in an at-risk/distressed community was independently associated with nonhome discharge [odds ratio (OR): 2.28, P =0.007] and longer length of stay (E:1.54, P =0.017).

CONCLUSIONS

Patients from socioeconomically disadvantaged communities experience longer hospitalizations and are more likely to be discharged to a rehabilitation or skilled nursing facility following PCDF. Social and economic barriers should be addressed as part of presurgical counseling and planning in elective spine surgery to mitigate these disparities and improve the quality and value of health care delivery, regardless of socioeconomic status.

Racial and ethnic disparity in shoulder surgery: a systematic review

BACKGROUND

Health care disparity exists in utilization and delivery of musculoskeletal care and continues to be an obstacle for orthopedic health care providers to mitigate. Racial and ethnic disparities exist within various surgical fields including orthopedic surgery and are expected to continue to rise in upcoming years. The aim of this systematic review is to analyze the racial and ethnic disparities on utilization and outcomes after common shoulder surgical procedures.

METHODS

A primary literature search was performed using PubMed, Embase, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases using comprehensive Medical Subject Headings and subject-heading search terms. Studies were included if they reported utilization and or outcomes across 2 or more racial/ethnic groups in patients (age >16) who underwent total shoulder arthroplasty (TSA), rotator cuff repair (RCR), arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of proximal humerus fracture (PHF). Baseline demographics, data on procedure utilization, perioperative measures including mortality, operative time, length of stay, readmission, and complications were extracted from included studies, and descriptive statistical analysis performed.

RESULTS

Eighteen studies were identified for full text review of which 13 found race and ethnicity as factors affecting utilization and outcomes in TSA, RCR, arthroscopic Bankart repair, Latarjet procedure, and open reduction internal fixation of PHF. Compared to White patients, Black patients were found to have decreased utilization, longer length of stay, and greater operative time and mortality after TSA; Black patients also had longer operative times and time to discharge, and lower levels of reported satisfaction after RCR. Hispanic/Latino ethnicity was reported as an independent risk factor for postoperative falls following TSA. Hispanic/Latino and Black patients have a higher risk of delayed surgery and greater risk of readmission after surgical treatment of PHF compared to patients of White race.

CONCLUSION

This systematic review highlights the limited literature reporting the existence of racial and ethnic disparities in utilization and outcomes after common shoulder surgical procedures. Additionally, there is a paucity of studies exploring the underlying etiology of racial and ethnic disparity in outcomes after shoulder surgery. More research is necessary to pave the way for evidence-based action plans to mitigate health care disparities after shoulder surgeries, but this review serves as a baseline for where efforts in direct improvement can begin.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis

OBJECTIVES

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity.

BACKGROUND

An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR.

METHODS

Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity.

RESULTS

Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR.

CONCLUSIONS

Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

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.

Neighborhood Deprivation and Association With Medical Complications, Emergency Department Use, and Readmissions in Shoulder Arthroplasty Patients

Background

Social determinants of health are prognostic indicators for patients undergoing orthopedic procedures.

Purpose

Using the area deprivation index (ADI), a validated, weighted index of material deprivation and poverty (a 0%-to-100% scale, with higher percentages indicating greater disadvantage), we sought to evaluate whether there are associations in shoulder arthroplasty patients between higher ADI and rates of (1) medical complications, (2) emergency department (ED) utilizations, (3) readmissions, and (4) costs.

Methods

We queried the PearlDiver nationwide database for patients who had undergone primary shoulder arthroplasty from 2010 to 2020. Patients from regions associated with high ADI (95%+) were 1:1 propensity matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 49,440 patients in total. Outcomes included 90-day complications, ED utilizations, readmissions, and costs. Logistic regression models computed odds ratios (ORs) of ADI on the dependent variables. P values of < .05 were significant.

Results

Patients from high ADI regions showed higher rates and odds of complications than those in the comparison group (10.84% vs 9.45%; OR: 1.10), including acute kidney injuries (1.73% vs 1.38%; OR: 1.23), urinary tract infections (3.19% vs 2.80%; OR: 1.13), and respiratory failures (0.49% vs 0.33%; OR: 1.44), but not increased ED visits (2.66% vs 2.71%; OR: 0.99) or readmissions (3.07% vs 2.96%; OR: 1.03). Patients from high ADI regions incurred higher costs on day of surgery ($8251 vs $7337) and at 90 days ($10,999 vs $9752).

Conclusions

This 10-year retrospective database study found that patients from high ADI regions undergoing primary shoulder arthroplasty had increased rates of all 90-day medical complications, suggesting that measures of social determinants of health could inform health care policy and improve post-discharge care in these patients.

Impact of Tibetan ethnicity and residence altitude on complications during total knee arthroplasty and difficulties of measurement of perioperative blood loss

PURPOSE

Tibetan patients undergoing total knee arthroplasty (TKA) have greater fluctuations in perioperative haemoglobin levels and blood hypercoagulability. This study was to investigate whether ethnicity and altitude affect perioperative blood loss and the risk of complications after TKA.

METHODS

We retrospectively enrolled 1,116 patients undergoing TKA for knee osteoarthritis at our hospital between January 2016 and September 2021. We divided patients into four groups according to whether they were of Tibetan or Han ethnicity and whether they lived above or below 2500 m above sea level. Primary outcomes were total, intraoperative, and hidden blood losses, while secondary outcomes were complications and homologous transfusion. Factors associated with increased blood loss were analyzed by multivariate regression.

RESULTS

Total blood loss was higher among patients residing at high altitude compared with lower altitude, whether they were of Han (794.6 mL vs. 667.2 mL, P = 0.020) or Tibetan (904.4 mL vs. 663.8 mL, P < 0.001). Total blood loss was similar between the two ethnic groups at the same altitude. Altitude, but not Tibetan ethnicity, remained associated with increased blood loss after being analyzed by multivariate regression. Complications among the four groups were generally similar, although the frequency of calf muscular venous thrombosis was higher among Tibetan patients, while the frequency of blood transfusion was higher among Han subjects.

CONCLUSIONS

Our findings indicate that residence at high altitude, but not ethnicity, may contribute to increased total blood loss during TKA. Thrombotic complications were more frequent among Tibetan than Han patients.

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.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient

BACKGROUND

Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care.

METHODS

A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant.

RESULTS

High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI.

CONCLUSIONS

Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.

LEVEL OF EVIDENCE

III.

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.

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

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

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.

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty

BACKGROUND

In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA).

METHODS

Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area.

RESULTS

When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively.

CONCLUSIONS

The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

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.

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.

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program

INTRODUCTION

Enhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP.

METHODS

A retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal-Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression.

RESULTS

Seven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01).

CONCLUSIONS

Implementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Examining racial disparities in utilization rate and perioperative outcomes following knee and hip arthroplasty

BACKGROUND

Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites.

RESULTS

Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66 days) compared to Asians (2.19 days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045).

CONCLUSIONS

Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Did the Comprehensive Care for Joint Replacement Bundled Payment Program Impact Sex Disparities in Total Hip and Knee Arthroplasties?

BACKGROUND

Sex disparities have been noted across various aspects of total hip/knee arthroplasty (THA/TKA). Given incentives to standardize care, bundled payment initiatives including the Comprehensive Care for Joint Replacement (CJR) program may reduce disparities. This study aimed to assess the CJR program's impact on sex disparities in THA/TKA care and outcomes.

METHODS

This retrospective cohort study included 259,673 THAs (61.7% women) and 506,311 TKAs (64.0% women) from a large national database (2013 to 2017). Sex disparities were assessed for care and outcomes related to the period (1) before surgery, (2) during hospitalization for THA/TKA, and (3) after discharge. Disparities were reported as women:men ratios. Difference-in-differences analyses estimated the impact of the CJR program on pre-existing sex disparities.

RESULTS

For both THA and TKA, women were less likely than men to present with a Charlson-Deyo comorbidity index >0 (women:men ratio 0.88 to 0.92), but were more likely to require blood transfusions (women:men ratio 1.48 to 1.79) and be discharged to institutional postacute care (women:men ratio 1.50 to 1.66). Difference-in-differences models demonstrated that the CJR bundled payment program reduced sex disparities in institutional postacute care discharges (THA: -2.28%; 95% confidence interval [CI] -4.20 to -0.35%, P = .02; TKA: -2.07%; 95% CI -3.93 to -0.20%; P = .03) and THA 90-day readmissions (-1.00%, 95% CI -1.88 to -0.13%, P = .02), indicating a differential impact of CJR in women versus men for some outcomes.

CONCLUSIONS

While sex disparities in THA/TKA persist, the CJR program demonstrates potential to impact such differences. Future research should focus on how potential mechanisms could be leveraged to reduce disparities.

Total Hip Arthroplasty in Chile Is Characterized By Low Utilization Rates and Disparity in Access

Background: Disparity in access to total hip arthroplasty (THA) is an internationally recognized phenomenon influenced by social and geographical factors. The Organisation for Economic Co-operation and Development (OECD) employs the utilization rates of THA to evaluate and compare healthcare utilization by its 37 country members, including Chile. Purpose: We sought to describe THA utilization rates in the elderly Chilean population and to compare it with data from other OECD countries. In addition, we sought to identify whether sociodemographic variables influence access to THA in Chile. Methods: We conducted a retrospective review of THA cases performed in Chile between 2016 and 2018 in patients aged 65 years and older in a large database regulated by the Ministry of Health; 8970 patients were included. Mean utilization rates (MURs) of THA within Chile's 346 administrative-territorial divisions (called communes) were calculated. We analyzed associations between the communal MUR and poverty, rurality, insurance type, and geographical health administration dependency. Results: The national MUR of THA in the elderly population in Chile was 144/100,000 for the period studied. The median communal MUR was 107 (interquartile range [IQR]: 66-153). A lower MUR of THA was observed in communes with higher poverty levels, higher rurality, and a lower rates of private insurance. After negative binomial regression analysis, only rurality rate and geographical healthcare service dependency were associated with MUR. Conclusions: This retrospective database study suggests that the utilization of THA in Chile is unequal and well below the average of other OECD countries. Higher rates of rurality and administrative healthcare dependence (a geographical/administrative factor) were associated with disparities in access to THA within Chile.

Outcome Disparities in Total Knee and Total Hip Arthroplasty among Native American Populations

BACKGROUND

No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities.

METHODS

This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses.

RESULTS

Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0).

CONCLUSION

AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study.

Racial variations in complications and costs following total knee arthroplasty: a retrospective matched cohort study

INTRODUCTION

In this study, we evaluate how race corresponds to specific complications and costs following total knee arthroplasty (TKA). Our hypothesis was that minority patients, comprising Black, Asian, and Hispanic patients, would have higher complication and revision rates and costs than White patients.

METHODS

Data from 2014 to 2016 were collected from a large commercial insurance database. TKA patients were assigned under Current Procedural Terminology (CPT-27447) and International Statistical Classification of Diseases (ICD-9-P-8154) codes. Minority patients were compared to White patients before and after matching for age, gender, and tobacco use, diabetes, and obesity comorbidities. Standardized complications, revisions, and total costs at 30 days, 90 days, and 1 year were compared between the groups using unequal variance t tests.

RESULTS

Overall, 140,601 White (92%), 10,247 Black (6.7%), 1072 Asian (0.67%), and 1725 Hispanic (1.1%) TKA patients were included. At baseline, minority patients had 7-10% longer lengths of stay (p = 0.0001) and Black and Hispanic patients had higher Charlson and Elixhauser comorbidity indices (p = 0.0001), while Asian patients had a lower Elixhauser comorbidity index (p < 0.0001). Black patients had significantly higher complication rates and higher rates of revision (p = 0.03). Minority patients were charged 10-32% more (p < 0.0001). Following matching, all minority patients had lengths of stay 8-10% longer (p = 0.001) and Black patients had higher Charlson and Elixhauser comorbidity indices (p < 0.0001) while Asian patients had a lower Elixhauser comorbidity index (p = 0.0008). Black patients had more equal complication rates and there was no significant difference in revisions in any minority cohort. All minority cohorts had significantly higher total costs at all time points, ranging from 9 to 31% (p < 0.0001).

CONCLUSION

Compared to White patients, Black patients had significantly increased rates of complications, along with greater total costs, but not revisions. Asian and Hispanic patients, however, did not have significant differences in complications or revisions yet still had higher costs. As a result, this study corroborates our hypothesis that Black patients have higher rates of complications and costs than White patients following total knee arthroplasty and recommends efforts be taken to tackle health inequities to create more fairness in healthcare. This same hypothesis, however, was not supported when evaluating Asian and Hispanic patients, probably because of the few patients included in the database and deserves further investigation.

When Do We Perform Elective Total Knee Arthroplasty? General and Demographic-Specific Trends of Preoperative Pain and Function among 10,327 Patients

Total knee arthroplasty (TKA) is the sole disease-modifying intervention for end-stage osteoarthritis. However, the temporal trends and stratification of age and patient demographics of pain and function levels at which surgeons perform TKA have not been characterized. The present investigation aimed to analyze the temporal trends of preoperative pain and functional patient-reported outcomes measures (PROMs) over the past 5 years when stratifying patient demographics. A prospective cohort of all patients who underwent primary elective TKA between January 2016 and December 2020 at a North American integrated tertiary health care system was retrospectively reviewed. The primary outcome was quarterly baseline (preoperative) pain and function PROM values before primary elective TKA. Evaluated PROMs included Knee Osteoarthritis Outcome Score (KOOS)-pain and KOOS-physical function shortform (PS) for the 5-year study period and were stratified by patient demographics (age, sex, race, and body mass index [BMI]). A total of 10,327 patients were analyzed. Preoperative pain levels remained unchanged over the study period for patients in the 45- to 64-year category (P-trend = 0.922). Conversely, there was a significant improvement in preoperative pain levels in the 65+ years group. Sex-stratified trends between males and females did not demonstrate a significant change in pre-TKA baseline pain over the study period (P-trend = 0.347 and P-trend = 0.0744). Both white and black patients demonstrated consistent KOOS-pain levels throughout the study period (P-trend = 0.0855 and P-trend = 0.626). Only white patients demonstrated improving preoperative KOOS-PS (P-trend = 0.0001), while black and "other" patients demonstrated consistent lower preoperative functional levels throughout the study period (P-trend = 0.456 and P-trend = 0.871). All BMI categories demonstrated relatively consistent preoperative KOOS-pain and KOOS-PS except for overweight and obese patients who demonstrated progressive improvement in preoperative KOOS-PS over the study period. Patients and surgeons are electing to perform primary TKA at higher levels of preoperative function. Stratification by race showed black patients did not experience a similar trend of improving function and exhibited a consistently lower functional level versus white patients. This disparity is likely to be multifactorial but may indicate underlying barriers to TKA access.

Impact of Pre-operative Opioid Use on Racial Disparities in Adverse Outcomes Post Total Knee and Hip Arthroplasty

INTRODUCTION

The growing opioid epidemic in the USA has underlying racial disparities dimensions. Also, studies have shown that patients from minority racial groups are at higher risk of adverse events following major orthopedic surgery. The aim of our study was to determine whether pre-operative opioid-use disorders (OUDs) impacted racial disparities in the likelihood of patients experiencing adverse post-operative outcomes following TKA and THA.

METHODS

Data about patients undergoing TKA and THA were collected from the 2005-2014 National Inpatient Sample databases. Regression modeling was used to assess the impact of OUDs on odds of adverse outcomes comparing racial groups. The adverse outcomes included any in-hospital post-surgical complications, prolonged length of stay (LOS), and nonhome discharge.

RESULTS

In our fully adjusted regression models using White patients as the reference group, we found that OUDs were associated with racial disparities in prolonged LOS and nonhome discharge. In the non-OUD group, Black patients had significantly higher odds of longer LOS (OR: 1.35, 95% CI: 1.26-1.46, p-value: < 0.0001), whereas those with history of OUD had non-significantly lower odds of longer LOS (OR: 0.94, 95% CI: 0.69-1.29, p-value: 0.71). Similarly, for the outcome of nonhome discharges, Black patients in the non-OUD group had significantly higher odds (OR: 1.31, 95% CI: 1.21-1.43, p-value: < 0.0001) and those with a history of OUD had non-significantly lower odds (OR: 0.91, 95% CI: 0.64-1.29, p-value: 0.59).

CONCLUSIONS

Significant racial disparities are present in adverse events among patients in the non-OUD group, but those disparities attenuated in the OUD group.

Marginalization Influences Access, Outcomes, and Discharge Destination Following Total Joint Arthroplasty in Canada's Universal Healthcare System

BACKGROUND

The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes.

METHODS

This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores.

RESULTS

The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046).

CONCLUSION

Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility.

LEVEL OF EVIDENCE

IV.

Evaluating the association between race and complications following pediatric upper extremity surgery

Race can influence perioperative care and outcomes in adult and pediatric orthopedic surgery. However, no prior study has evaluated any associations between race and complications following upper extremity surgery in pediatric patients. Thus, the purpose of this study was to evaluate whether there are any differences in risks for complications, readmission, or mortality following upper extremity surgery between African American and Caucasian pediatric patients. Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were categorized into two cohorts: patients who were Caucasian and patients who were African American. Differences in demographics, comorbidities, and postoperative complications were assessed and compared between the two-patient population using bivariate and multivariable regression analyses. Of the 25 848 pediatric patients who underwent upper extremity surgeries, 21 693 (83.9%) were Caucasian, and 4155 (16.1%) were African American. Compared to Caucasian patients, African American patients were more likely to have a higher American Society of Anesthesiologists classification ( P  < 0.001), as well as pulmonary comorbidities ( P  < 0.001) and hematologic disorders ( P  = 0.004). Following adjustment on multivariable regression analysis to control for baseline characteristics, there were no differences in any postoperative complications between Caucasian and African American patients. In conclusion, African American pediatric patients are not at an increased risk for postoperative complications compared to Caucasian patients following upper extremity surgery. Race should not be used independently when evaluating patient risk for postoperative complications. Level of Evidence: III.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Healthcare Market-Level and Hospital-Level Disparities in Access to and Utilization of High-Quality Hip and Knee Replacement Hospitals Among Medicare Beneficiaries

INTRODUCTION

This study aimed to determine whether healthcare markets with higher social vulnerability have lower access to high-quality hip and knee replacement hospitals and whether hospitals that serve a higher percentage of low-income patients are less likely to be designated as high-quality.

METHODS

This cross-sectional study used 2021 Centers for Medicare and Medicaid Services outcome measures and 2022 Joint Commission (JC) process-of-care measures to identify hospitals performing high-quality hip and knee replacement. A total of 2,682 hospitals and 304 healthcare markets were included. For the market-level analysis, we assessed the association of social vulnerability with the presence of a high-quality hip and knee replacement center. For the hospital-level analysis, we assessed the association of disproportionate share hospital (DSH) percentage with each high-quality designation. Healthcare markets were approximated by hospital referral regions. All associations were assessed with fractional regressions using generalized linear models with binomial family and logit links.

RESULTS

We found that healthcare markets in the most vulnerable quartile were less likely to have a hip and knee replacement hospital that did better than the national average (odds ratio [OR] 0.22, P = 0.02) but not more or less likely to have a hospital certified as advanced by JC (OR 0.41, P = 0.16). We found that hip and knee replacement hospitals in the highest DSH quartile were less likely to be designated by the Centers for Medicare and Medicaid Services as better than the national average (OR 0.18, P = 0.001) but not more or less likely to be certified as advanced by JC (OR 1.40, P = 0.28).

DISCUSSION

Geographic distribution of high-quality hospitals may contribute to socioeconomic disparities in patients' access to and utilization of high-quality hip and knee replacement. Equal access to and utilization of hospitals with high-quality surgical processes does not necessarily indicate equitable access to and utilization of hospitals with high-quality outcomes.

LEVEL OF EVIDENCE

Level III.

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III, retrospective cohort study.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release

BACKGROUND

Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity.

METHODS

Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery.

RESULTS

The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively).

CONCLUSIONS

Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted.

LEVEL OF EVIDENCE

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

Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State.

SUMMARY OF BACKGROUND DATA

Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity.

MATERIALS AND METHODS

We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity.

RESULTS

Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001).

CONCLUSIONS

We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery.

LEVEL OF EVIDENCE

III.

Mobile Application's Effect on Patient Satisfaction and Compliance in Total Joint Arthroplasty: A Systematic Review and Meta-analysis

Use of mobile applications to improve patient engagement is particularly promising in total joint arthroplasty (TJA) whereby successful outcomes are predicated by patient engagement. In accordance with published guidelines by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, studies were searched, screened, and appraised for quality on various search engines. Hedges' g or odds ratios of patient adherence were reported. Twelve studies met the inclusion criteria, and the average age of 9,521 patients included was 60 years. Six studies concluded that mobile applications improved patients' satisfaction, with Hedges' g revealing an effect size of 1.64 (95% confidence interval [CI] 0.90 to 2.37), P < 0.001, in favor of mobile applications increasing patient satisfaction. Six studies reported improvements in compliance demonstrating an odds ratio for improved adherence of 4.57 (95% CI, 1.66 to 12.62), P < 0.001. Two studies reported a reduction in unscheduled office or emergency department visits. With evolving reimbursement policies linked to outcomes paired with the exponentially increasing volume of TJA performed, innovative ways to efficiently deliver high-quality care are in demand. Our systematic review is limited by a dearth of research on the nascent technology, but the available data suggest that mobile applications may enhance patient satisfaction, improve compliance, and reduce unscheduled visits after TJA.