Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population

Abstract

Background: Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system. Methods: A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders. Results: Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients. Conclusions: In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary Total Hip Arthroplasty in Hispanic/Latino Patients: An Updated Nationwide Analysis of Length of Stay, 30-Day Outcomes, and Risk Factors

“…Contrary to previous reports, mortality [ [6] , [7] , [8] , [9] , [10] ] and overall rates of 30-day outcomes were comparable between Hispanic and Latino and non-Hispanic white patients. This finding contributes to the ongoing discussion regarding the role of low socioeconomic status or income (frequently more prevalent in Hispanic/Latino populations) as it relates to THA outcomes.…”

“…The exponential growth in procedure utilization raises the potential for worsened disparities among racial and ethnic minorities who have traditionally experienced lower access to care and worse outcomes for THA [ [3] , [4] , [5] ]. For example, minority patients have been shown to experience increased postoperative pain, prolonged hospitalization, and higher rates of emergency department visits, complications, and mortality [ [6] , [7] , [8] , [9] , [10] ].…”

Where Do We Stand Today on Racial and Ethnic Health Disparities? An Analysis of Primary Total Hip Arthroplasty From a 2011–2017 National Database

“…In addition, minority patients are more likely to be part of restrictive referral networks and to undergo THA at low-volume hospitals despite living close to high-volume hospitals [25,26]. Given that low-volume hospitals are associated with higher complication rates and poorer outcomes [27], this may further propagate the cycle of distrust and may explain their higher rates of lower postoperative satisfaction [7,13].…”

“…Providing culturally appropriate information and services can assist patients in understanding and adhering to treatment options. Improving minority access to care and perioperative optimization holds significant value as studies have shown that in a universally insured and integrated health-care system, minorities have had outcomes similar to or better than whites after undergoing THA [13]. Seeking to improve patients' SDOH is the key of a comprehensive value-based approach to health care.…”

“…A fundamental obstacle in achieving this goal, as highlighted by the American Academy of Orthopaedic Surgeons, has been the lack of clinical research to adequately understand and effectively address health disparities [5]. Available data have been limited by analyses of patients from specific institutions [4,7,10,11], health-care systems [12][13][14], geographic regions [15], payer types [16,17], or minority groups [4,7,10,11,14,17,18], making generalizations difficult. Furthermore, there have been numerous changes and surgical advancements in the past decade, which aimed to improve health outcomes for all patients in general and those undergoing arthroplasty in particular.…”