Comorbidity Burden Contributing to Racial Disparities in Outpatient Versus Inpatient Total Knee Arthroplasty

Abstract

Introduction: Outpatient total knee arthroplasty (TKA) is increasingly common in the setting of early-recovery protocols, value-based care, and removal from the inpatient-only list by the Centers for Medicare & Medicaid Services. Given the established racial disparities that exist in different aspects of total joint arthroplasty, we aimed to investigate whether racial and ethnic disparities exist in outpatient compared with inpatient TKA. Methods: This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We queried TKAs done in 2018. Demographics, inpatient (≥2 midnights) versus outpatient (≤1 midnight) status, comorbidities, and perioperative events/complications were recorded. We analyzed differences between racial/ethnic groups and predictors of inpatient versus outpatient surgery, and outcomes. Results: A total of 54,582 patients were included (83.2% Caucasian, 9.2% African American [AA], 4.5% Hispanic, 2.4% Asian, and 0.6% Native American). AA had the highest mean body mass index, American Society of Anesthesiologists score, and comorbidity burden. AA had the lowest rate of outpatient TKA (18.3%) and Asians the highest rate of outpatient TKA (31.4%, P < 0.0001). AA had the highest postoperative transfusion rate (1.8%, P < 0.0001) and highest rate of discharge to acute rehab (8.4%). Asians had the highest rate of postoperative cardiac arrest and urinary tract infection. AA had the highest rate of acute kidney injury within 30 days. Regression analyses revealed that AAs were more likely to undergo inpatient surgery (odds ratio [OR], 2.58; confidence interval [CI], 1.57-4.23; P = 0.001) and discharge to rehab/skilled nursing facility [SNF] (OR, 2.86; CI, 1.66-4.92; P = 0.001). Asian patients were more likely to undergo outpatient surgery (OR, 2.48, CI, 1.47-4.18, P = 0.001) and discharged to rehab/SNF (OR, 2.41, CI, 1.36-4.25, P = 0.001). Caucasians were more likely to undergo outpatient surgery (OR, 1.62, CI, 1.34-1.97, P = 0.001) and less likely discharged to rehab/SNF (OR, 0.73, CI, 0.60-0.88, P = 0.001). When controlling for comorbidities, race was not an independent risk factor for 30-day complications or inpatient versus outpatient surgery. Discussion: Differences in indications for outpatient TKA between races/ethnicities seem to be highly associated with comorbidity burden and preoperative baseline differences, not race alone. Appropriate patient optimization for either outpatient or inpatient TKA may reduce disparities between groups in either care setting.

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures

“…Such results may be potentially due to factors such as language barriers, resource disparity, or geographical issues. While there are no previous studies on the socioeconomic patient characteristic differences between inpatient or outpatient care for pediatric SCHF patients, recent studies on total hip and total knee arthroplasties have emphasized that higher SDI scores are associated with inpatient care, alongside African American race, and existence of comorbidities [ 16 , 24 ]. More specifically, a recent study of adult ambulatory surgical care in New York also reported that Black and Hispanic patients had higher odds of receiving inpatient care [ 25 ].…”

Lower Rates of Ceramic Femoral Head Use in Non-White Patients in the United States, a National Registry Study

“…Finally, given prior research showing non-White patients tend to present for arthroplasty later in disease progression, with more severe arthritis, we were surprised that in our study population Black patients were younger (62.3 vs 68.6) and had lower medical comorbidity (CCI of 2.45 vs 2.92) compared to White non-Hispanic patients. In administrative database and retrospective institutional studies, non-White patients have been found to have higher rates of baseline comorbidity at the time of primary and revision arthroplasty [ 9 , 45 , 48 , 49 ]. It is unclear why comorbidity levels were lower in non-White patients in our study, although this likely reflects a difference in the underlying population captured by the AJRR.…”

Time to Reflect and Take Action on Health Disparities and Health Inequities

“…Black patients have more negative hospital metrics as compared with White patients with longer length of stay (LOS) (Amen et al, 2020; Lan & Kamath, 2017; Larrieux, 2017; Singh et al, 2014). There is a greater likelihood that Black patients will be discharged to a skilled nursing facility as compared with home/home health (Amen et al, 2020; Lan & Kamath, 2017; Lasater & Mchugh, 2016; Singh et al, 2014, 2019), which is of concern, as discharge to locations other than home is associated with lower patient satisfaction and poorer clinical outcomes (Wu et al, 2021). Also, 30- and 90-day readmissions are greater for Black patients (Arroyo et al, 2019; Oronce et al, 2015; Wu et al, 2021).…”

“…Racial disparities associated with arthroplasty have been identified in: (1) rates in use of arthroplasty; (2) hospital metric outcomes; and (3) postoperative outcomes (Amen et al, 2020). The majority of studies examining these disparities have focused on a comparison of Black and White populations, with little data on other minority groups (Mehta et al, 2018;Wu et al, 2021). Unfortunately, much of the literature examining outcomes THA and TKA does not examine race.…”