INTRODUCTION
Racial disparities are pervasive throughout our healthcare system and are closely related to overarching disparities that affect minority populations in society as a whole. Furthermore there are concerns that the recent changes in US healthcare infrastructure have shifted the focus to providing more cost-effective patient care, leading to a reduction in care for high-risk minority patient populations (Galvani et al. 2020). A recent study demonstrated that 83% of physicians report feeling pressure to avoid access to total joint replacement (TJR) in patients with limited social support (Yates, Jones, Nelson, et al. 2021). As TJR becomes increasingly prevalent due to the aging population in the US, it is vital to address the existing racial disparities that could be exacerbated by the increased demand.
Current literature demonstrates the impact of racial disparities on access to care, utilization of services, and patient outcomes following TJR (Chun et al. 2021; Hu, Hu, Lee, et al. 2022; Amen et al. 2020; Alvarez, McKeon, Spitzer, et al. 2022). In particular, underutilization of TJR has been identified in Black patients despite a higher prevalence of disease such as osteoarthritis (Chen et al. 2013; Shahid and Singh 2016). Furthermore, postoperative complications after TJR are experienced at disproportionately higher rates by minority populations (Aseltine, Wang, Benthien, et al. 2019; Klemt et al. 2021; Goodman, Parks, McHugh, et al. 2016; Cusano et al. 2021; Hinman et al. 2020; Bass, Do, Mehta, et al. 2021; Pierce, Elmallah, Lavernia, et al. 2015; Faison, Harrell, and Semel 2021). The factors that affect racial disparity in healthcare are complex and inconsistent depending on the demographics of the patient population studied (Klemt et al. 2021; Cusano et al. 2021; Hinman et al. 2020; Pierce, Elmallah, Lavernia, et al. 2015; Okike et al. 2019; Cavanaugh, Rauh, Thompson, et al. 2020). Some studies have demonstrated an increased risk of postoperative complications, readmission, and revision surgery in minority patients (Klemt et al. 2021; Cusano et al. 2021; Hinman et al. 2020; Bass, Do, Mehta, et al. 2021; Pierce, Elmallah, Lavernia, et al. 2015; Cavanaugh, Rauh, Thompson, et al. 2020) while others have failed to demonstrate differences across racial groups in other outcomes after TJR (Cusano et al. 2021; Hinman et al. 2020).
To create effective interventions to alleviate racial disparities, it is imperative to elucidate with more certainty where complications and readmission are being experienced disproportionately by minority patients. Further, avoiding preventable readmission is a prominent target for cost savings in TJR, and identifying complications associated with hospital readmission is critically important for predictive modeling and for decreasing the number of TJR readmissions (Adelani et al. 2018; Yu et al. 2016). Additional clarity concerning differences in complications and readmission rates across racial groups could help bring to light the root causes of poorer outcomes allowing for better protection of vulnerable populations from selection bias and mitigating rising healthcare costs. Therefore, the purpose of this study was to evaluate the impact of racial disparities on postoperative complications and readmission rates following TJA.
METHODS
Patient Selection and Data Collection
A large healthcare network database was queried to identify all patients who underwent a total joint arthroplasty (TJA) (TKA, total hip arthroplasty (THA), and total shoulder arthroplasty (TSA)) in the regional healthcare system between 2017 and 2021 with a minimum follow-up of 90 days. CPT codes used were 27447 for primary TKA, 2347 for primary SA, and 27130 for primary THA. The database comprised of patients with different types of insurance. Patient demographics including age, gender, body mass index (BMI), and race were collected. Race was defined as White, Black, Hispanic, Asian, and Other.
Patient outcomes collected included length of stay, postoperative medical complications, postoperative surgical complications, hospital readmission status at 30 and 90 days postoperatively, and emergency room (ER) visits up to 90 days. Postoperative medical complications included sepsis, bacterial infections, pneumonia, acute/chronic kidney failure, disruption of the surgical wound, embolism, and thrombosis. Postoperative surgical complications included dislocation, instability, periprosthetic joint infection, periprosthetic fracture, aseptic loosening, hardware failure, revision, and wear and osteolysis (Supplemental Table 1).
Statistical Analysis
Categorical variables were compared using a chi-squared test and continuous variables were compared using analysis of variance. Multivariate logistic regression analysis was performed to assess for associations between postoperative medical complications and postoperative surgical complications with patient race. Odds ratio estimates and 95% confidence intervals were calculated for each of the composite outcomes for patients undergoing TJA. The level of significance was established at p < .05. All statistical analyses were conducted using SAS version 9.4 software (SAS Institute, Cary, NC, USA).
RESULTS
Patient Demographics
A total of 16,940 patients consisting of 62% female with a mean age of 71 years and mean BMI of 29.5 kg/m2 were included. The cohort included 12.3% Black (n=2089), 24.1% Hispanic (n=4,077), 0.8% Asian (n=131), 1.2% Other (n=203), and 61.6% White (n=10,440) patients. The average length of stay was 3.4 days (Table 1).
Postoperative Complications
Postoperative medical complications were reported in 5.3% (n = 894) of patients and 4.4% (n = 740) of patients experienced postoperative surgical complications. No significant difference was reported between the Black (5.8%), Asian (6.9%), Hispanic (5.2%) or Other racial groups (4.4%) in postoperative medical complications when compared to White patients (5.2%) (p=0.5721). Additionally, no significant difference was reported between the Black (5.2%), Asian (5.3%), Hispanic (4.2%) or Other racial groups (3.9%) in postoperative surgical complications when compared to White patients (4.3%) (p=0.6200). (Table 2 and Table 3).
Readmission Rates
When assessing postoperative hospital readmission status, 8.6% (n = 1,461) of patients were readmitted within 30 days, 14% (n = 2370) of patients were readmitted within 60 days, and 20.3% (n = 3,446) of patients were readmitted within 90 days. Furthermore, 7.2% (n = 1,216) visited the ER within 90 days of surgery (Table 3). No significant difference was reported between the Black, Asian, Hispanic or Other racial groups in readmission at 30 days when compared to White patients (p=0.2215).
At 60-day and 90-day readmissions, Hispanic patients were 17% (OR, 0.836; 95% CI: 0.750-0.933) and 14% (OR, 0.864; 95% CI: 0.787 – 0.948) less likely to be readmitted compared to White patients, respectively (p = 0.0208). Black, Asian, and Other race patients were not significantly more likely to be readmitted to the hospital within 60 or 90 days when compared to White patients. No significant difference in ER visits at 90 days was reported in any race when compared to White patients (p=0.2215).
DISCUSSION
There has been an increasing interest in creating a cost-effective healthcare system among hospitals, physicians, and patients. With recent changes in healthcare infrastructure to meet these needs, there is growing concern that changes may negatively impact some patient populations more than others. As access to appropriate and reliable healthcare is an important marker of social equality, it is of interest to determine where differences in care may arise. The results of this study revealed that racial differences were not significantly associated with postoperative medical or surgical complications in patients who underwent a TJR. However, there was a high overall 90-day readmission rate to almost 20% of patients. Although, Hispanic patients undergoing TJR had a lower likelihood of readmission at 60 and 90 days postoperative compared to White patients. Although race was not defined as a factor influencing postoperative complications, except for Hispanics with a slightly lower 60 and 90 day readmission, efforts need to be directed toward understanding other risk factors and addressing causes for readmission to address better cost-efficient healthcare. Specifically with CJR and value based care penalizing hospitals for readmissions better efforts and preoperative optimization are clearly needed to impact these costly high readmission rates.
The findings of our study conflict with previous literature, which has demonstrated increased postoperative complications and readmission rates of racial minorities. In a large systematic review, Alvarez et al. found that Black and Hispanic patients had significantly higher rates of postoperative complications and readmission rates following lower extremity arthroplasties (Alvarez, McKeon, Spitzer, et al. 2022). With many studies indicting persistent disparities, our results support improvement in racial disparities. However, it remains difficult to account for all differences between minority groups that may have an indirect impact on healthcare outcomes. For example, access to proper medical care remains a hurdle in medicine and is known to affect races to different degrees (Caraballo, Ndumele, Roy, et al. 2022). Additionally, racial differences in preoperative functional status may affect postoperative data, as poorer preoperative function is associated with worse postoperative outcomes (Fortin, Clarke, Joseph, et al. 1999; Hofstede, Gademan, Stijnen, et al. 2018). Previous studies, such as the analysis by Alvarez et al. have reported racial disparities in post-surgical outcomes attributing these differences to access to care and preoperative functional status, as well as treatment in lower-quality, lower-volume healthcare facilities (Alvarez, McKeon, Spitzer, et al. 2022; Cavanaugh, Rauh, Thompson, et al. 2020).
Our study did not show increases in postoperative complications and readmission rates among minority patients in a single healthcare system network suggesting that perhaps access to healthcare is the biggest contributor to disparities in outcomes for racial minorities. Access to healthcare is a factor more significantly impacting racial minorities and contributes to negative outcomes and increased disparities in health.
With the ever-changing healthcare industry, these results may indicate that the efforts made to correct the impacts of racial disparities in healthcare are improving. Systematic discrimination has been a continuous uphill battle for decades and is often perpetuated by large overarching institutions. Effectively addressing these discrepancies is vital to building a healthcare system with equal quality care for all. Improving data systems, increasing regulations, applying new initiatives to properly train medical professionals, and recruiting medical providers from various backgrounds are all methods that have been implemented to attempt to close these gaps (Williams and Rucker 2000). Although many studies have shown racial impact on access to care, utilization of services, and patient outcomes for patients undergoing a TJR, this large cohort study provides hope that there is some success in the attempts to create an equitable healthcare system (Chun et al. 2021; Hu, Hu, Lee, et al. 2022; Amen et al. 2020; Alvarez, McKeon, Spitzer, et al. 2022).
This study, like any analysis of large databases, is subject to limitations. The retrospective nature of this study results in inherit bias based on the data collected and requested for analyses. Our results on postoperative medical and surgical complication rates were not stratified by surgery type (THA, TKA, and TSA) and were instead grouped into TJA. Future studies to delineate specific procedures and account for additional confounding variables will allow for more specific associations to be assessed for race-based differences in outcomes. Additionally, we did not stratify for surgeon volume or training, hospital location, hospital volume, or prosthetic type which can all be confounding variables. Despite these limitations, the study’s strength lies in the large inclusive sample size.
CONCLUSION
This study found that this cohort of total joint patients had a high readmission rate of up to 20% within 90 days. Although race did not appear to be a significant determinant of additional ER visits or readmissions, there was some variation seen amongst Hispanic patients undergoing TJR with a lower likelihood of readmission at 60 and 90 days postoperative. Further research is needed on the cultural impact of healthcare resource utilization and complications after TJR, and perhaps more community integration may be key to minimizing costly healthcare resources.