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

The Effect of Socioeconomic Status and Social Deprivation on Outcomes Following Reverse Shoulder Arthroplasty: Data From an Urban Academic Center

PURPOSE

Rotator cuff tear arthropathy (CTA) and glenohumeral osteoarthritis pose notable financial and symptomatic burdens on the aging population. This study aims to determine how social determinants of health affect patient-reported outcomes following reverse total shoulder arthroplasty (rTSA), the surgical treatment for cuff tear arthropathy and glenohumeral osteoarthritis.

METHODS

A single-center retrospective review was conducted for patients who underwent rTSA between 2017 and 2022. Zip codes were used to determine income levels, as defined by the U.S. Department of Housing and Urban Development (HUD) and the Federal Reserve (FED). Social disadvantage was quantified using Social Deprivation Index (SDI). The American Shoulder and Elbow Score (ASES) was obtained by chart review or calls at a minimum 2-year follow-up. Statistical analysis was notable done using analysis of variance, Kruskal-Wallis, and Pearson chi-square tests.

RESULTS

A total of 121 patients met inclusion criteria. Of those included, 101 patients (83%) had 2-year ASES scores. Patients were divided into three cohorts based on HUD income status, FED income status, and SDI score. A difference was observed in 2-year ASES scores when stratified by HUD subgroups (P = 0.011); however, no difference was observed in 2-year ASES scores between FED or SDI subgroups. Analysis yielded no differences in pain scores, range of motion, total length of hospital stay, complications, or revision rates between all subgroups (all, P > 0.05).

DISCUSSION

The results of this study yielded no notable difference in postoperative ASES scores between FED classes or SDI subgroups. Although a difference was observed in ASES scores between HUD classes, it may be clinically negligible. Contrary to previous literature, socioeconomic status and social deprivation did not affect postoperative outcomes within our patient population.

CONCLUSION

Social determinants of health did not affect outcomes of patients undergoing a rTSA within the first 2 years after surgery.

LEVEL OF EVIDENCE

III.

Patient race and ethnicity are associated with higher unplanned 90-day emergency department visits and readmissions but not 10-year all-cause complications or reoperations: a matched cohort analysis of primary shoulder arthroplasties

Background

Within orthopedic surgery, there remain limited data evaluating the impact of racial and socioeconomic disparities on outcomes of primary shoulder arthroplasty (SA) over time. As such, we analyzed both short- and longer-term outcome differences in complications, reoperations, and revision surgery of primary SA when performed in non-White patients when compared to a matched cohort of White patients who had undergone SA.

Methods

Over a 39-year period (1981-2020), an institutional Total Joint Registry Database was utilized to identify all non-White patients (Asian/Pacific Islander, Black, Hispanic or Latino, American Indian/Alaska Native, other) who underwent primary SA with a minimum of 2 years of follow-up. The search identified 275 primary SA (46 hemiarthroplasties, 97 anatomic total shoulder arthroplasties, and 132 reverse total shoulder arthroplasties). The ethnicity composition was 8.7% Asian, 27.3% Black, 37.8% Hispanic, 12.4% American Indian, and 13.8% other. This cohort was matched 1:2 according to age, sex, diagnosis, implant, and surgical year to a control group of 550 White patients who had undergone SA. The rates of medical and surgical complications, reoperations, revisions, and implant survivorship were assessed. The mean follow-up time was 6.3 years (range, 2 to 40 years).

Results

Comparisons between the non-White and White matched cohorts demonstrated a higher rate of tobacco use (14.2% vs. 10.5%; P < .001), diabetes (21.5% vs. 11.8%; P < .001), length of stay (1.9 vs. 1.6 days; P = .014), and a lower rate of private commercial insurance (27.3% vs. 44.5%; P < .001 in the non-White cohort. Within the first 90 days after surgery, non-White patients had a higher rate of emergency department visits (5.5% vs. 0.9%; P < .001) and unplanned readmissions (2.9% vs. 0.7%; P = .014). After the first 90 postoperative days, there were no differences regarding medical (1.8% vs. 0.7%; P = .135) or surgical complications (12.0% vs. 13.6%; P = .446). Ten-year survivorship free of all-cause complication (76.8% vs. 81.5%; P = .370), reoperation (84.9% vs. 89.8%; P = .492), and revision (89.3% vs. 91.4%; P = .715) were similar between the non-White and White cohorts.

Discussion

After accounting for age, sex, and surgical indication, patient race and ethnicity were not associated with an increased risk of long-term all-cause complications, reoperations, or revision surgery after primary SA. However, within the first 90 postoperative days, non-White patients had a higher likelihood of unplanned emergency room visits and readmissions.

The Effect of Race and Social Vulnerability on the Management of Thumb Carpometacarpal Osteoarthritis

Introduction Thumb carpometacarpal (CMC) osteoarthritis is one of the most common hand arthropathies. There is significant variability in treatment, and understanding how race and social vulnerability impact treatment decisions is essential for equitable care. The purpose of this study is to examine the effect of race and social vulnerability on the management of patients with thumb CMC osteoarthritis. Methods A retrospective review of 270 patients presenting to one community-based health system for CMC osteoarthritis from December 2014 to February 2023 was performed. Patient demographics, comorbidities, patient-reported outcomes, social vulnerability index (SVI), and Eaton-Littler classification were collected. Patients were classified by race and SVI. The primary outcome of interest was CMC arthroplasty. Secondary outcomes included non-operative treatment and time to surgery. Results On average, non-White patients were younger (p=0.033), had increased BMI (p=0.001), and were more likely females (p=0.002). Additionally, non-White patients were more socially vulnerable overall than White patients (p<0.001). Non-White patients had a higher rate of steroid injection (p=0.018), a lower rate of splinting (p<0.001), and a lower rate of CMC arthroplasty (21.5% vs. 35.6%; p=0.038). On multivariate analysis, non-White patients were 2.17 (p=0.035) times less likely to have CMC arthroplasty than White patients. Conclusions Non-White and higher social vulnerability patients are less likely to receive a splint and proceed to CMC arthroplasty. On multivariate analysis, the White race patients were predictive of CMC arthroplasty. On multivariate analysis, White race patients were associated with increased odds of CMC arthroplasty. These findings highlight the association between socioeconomic and racial factors and treatment decisions, suggesting a need for targeted strategies to ensure equitable care.

Demographic Disparities and Outcomes Following Hip Arthroscopy: Exploring the Impact of Social Determinants of Health in Femoroacetabular Impingement Syndrome

BACKGROUND

The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression.

RESULTS

In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all).

CONCLUSIONS

Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile.

LEVEL OF EVIDENCE

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

Sensitivity, Specificity, and Reliability of the CTS-6 for Carpal Tunnel Syndrome Administered by Medical Assistants

PURPOSE

The CTS-6 can be used clinically to diagnose carpal tunnel syndrome (CTS) and has demonstrated high levels of interrater reliability when administered by nonexpert clinicians. Our purpose was to assess sensitivity (Sn), specificity (Sp), and interrater reliability of the CTS-6 when administered by medical assistants (MAs).

METHODS

A series of patients presenting to an academic, upper-extremity surgery clinic were screened using CTS-6 between May and June of 2023. The CTS-6 was first administered by one of seven MAs and then by one of four fellowship-trained upper-extremity surgeons. In addition to recording baseline demographics, the results of each of the six history and examination components of the CTS-6 were recorded, as was the cumulative CTS-6 score (0-26). Surgeons were blinded to the scores obtained by the MAs. Interrater reliability (Cohen's kappa) was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 items. Sensitivity/specificity was calculated for the MA-administered CTS-6, using the score obtained by the surgeon as the reference standard. A CTS-6 score >12 was considered diagnostic of CTS.

RESULTS

Two hundred eighteen patients were included, and 26% had a diagnosis of CTS. The MA group demonstrated a Sn/Sp of 84%/91% for the diagnosis of CTS. Interrater reliability was substantial (Cohen's kappa: 0.72, 95% confidence interval: 0.62-0.83) for MAs compared with hand surgeons for the diagnosis of CTS. For individual CTS-6 components, agreement was lowest for the assessment of two-point discrimination (fair) and highest for the assessment of subjective numbness (near perfect).

CONCLUSIONS

The CTS-6 demonstrates substantial reliability and high Sn/Sp when administrated by MAs in an upper-extremity clinic. These data may be used to inform the development of CTS screening programs and future investigations in the primary care setting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.