Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients

Abstract

Background Demographic factors have been implicated in THA and TKA outcome disparities. Specifically, patients' racial backgrounds have been reported to influence outcomes after surgery, including length of stay, discharge disposition, and inpatient readmissions. However, in the United States, health-impacting socioeconomic disadvantage is sometimes associated with racial differences in ways that can result in important confounding, thereby raising the question of whether race-associated post-THA/TKA adverse outcomes are an independent function of race or a byproduct of confounding from socioeconomic deprivation, which is potentially addressable. To explore this, we used the Area Deprivation Index (ADI) as a proxy for socioeconomic disadvantage, since it is a socioeconomic parameter that estimates the likely deprivation associated with a patient's home address. Questions/purposesThe goal of this study was to investigate (1) whether race (in this study, Black versus White) was independently associated with adverse outcomes, including prolonged length of stay (LOS > 3 days), nonhome discharge, 90-day readmission, and emergency department (ED) visits while controlling for age, gender, BMI, smoking, Charlson comorbidity index (CCI), and insurance; and (2) whether socioeconomic disadvantage, measured by ADI, substantially mediated any association between race and any of the aforementioned measured outcomes. Methods Between November 2018 and December 2019, 2638 underwent elective primary THA and 4915 patients underwent elective primary TKA for osteoarthritis at one of seven hospitals within a single academic center. Overall, 12% (742 of 5948) of patients were Black and 88% (5206 of 5948) were White. We included patients with complete demographic data, ADI data, and who were of Black or White race; with these criteria, 11% (293 of 2638) were excluded in the THA group, and 27% (1312 of 4915) of patients were excluded in the TKA group. In this retrospective, comparative study, patient follow-up was obtained using a longitudinally maintained database, leaving 89% (2345 of 2638) and 73% (3603 of 4915) for analysis in the THA and TKA groups, respectively. For both THA and TKA, Black patients had higher ADI scores, slightly higher BMIs, and were more likely to be current smokers at baseline. Furthermore, within the TKA cohort there was a higher proportion of Black women compared with White women. Multivariable regression analysis was utilized to assess associations between race and LOS of 3 or more days, nonhome discharge disposition, 90-dayThe authors certify that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Ethical appro...

Editor’s Spotlight/Take 5: Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty

“…Another paper on a related theme this month found that although Black patients were more likely than White patients to experience safety-related complications of spine surgery, a substantial part of this finding—nearly half of it, for some endpoints—was attributable to elements of social disadvantage other than race, as measured by the Social Vulnerability Index [4]. This finding seemed consistent across the analyses published in this symposium that asked related questions in this way [6].…”

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy

“…42,43 Devotion of resources to overcome language barriers and medical transportation effort may help reduce these disparities. 44,45 Our subanalysis of cost-center-specific charges identified charge differences of $2,110 for Black and $18,657 for Hispanic patients compared with White patients, although this difference was almost 10 times higher for Hispanic patients. Higher accommodation charges accounted for 86% of the difference for Black patients and may present a target for intervention.…”

CORR Insights®: Racial Disparities in Outcomes After THA and TKA Are Substantially Mediated by Socioeconomic Disadvantage Both in Black and White Patients

“…Apart from acknowledging the existence of healthcare disparities, it is critical for us, as providers, to spread awareness and educate peers, our care teams, and patients about the existence of health disparities. Discussing articles such as Hadad et al's [4] with our peers and residents in a journal club and volunteering for community seminars in the underprivileged community to address fears and culture-related beliefs about the benefit of orthopaedic procedures such as total joint arthroplasty to treat end-stage arthritis are ways we can spread awareness about health inequity.…”

“…Socioeconomic disparity is a big cause of healthcare disparities and is closely tied to racial disparities. A study in this month’s Clinical Orthopaedics and Related Research ® by Hadad et al [4] is an important contribution to our efforts to understand what really drives these disparities, rather than focusing—as so much earlier research has—on simplistic associations between race and outcomes of interest. The authors studied the relationship and interplay of race (Black versus White) and socioeconomic status, as determined by the Area Deprivation Index, with outcomes after TKA and THA.…”