No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used

Abstract

Background Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. Questions/purposes (1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? Methods In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 6 10 years and 427 non-White patients who were 64% (271) female with mean age 80 6 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially Two authors (SRK, KAE) are coinventors of the Personacare software that is owned by New York University. The Personacare software may use the algorithm described by this research. All ICMJE Conflict of Interest Forms for authors and Cli...

Reply to the Letter to the Editor: No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways are Used

“…Okike et al conclude that their results may have been because of the standardized pathways provided by their managed care plan. We agree with their supposition and believe our study [4] supports the notion that equal care in the hospital setting provided by a standardized hip fracture pathway, regardless of racial or ethnic differences in social determinants of health, can equalize outcomes.…”

“…We performed a subgroup analysis [4] looking at race or ethnicity broken into cohorts of White, Black, Hispanic, Asian, and other. Our multivariate regression analysis, with race and ethnicity further delineated in this manner, did not yield significant correlations of race and ethnicity with any of our reported outcomes.…”

CORR Insights®: No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways Are Used

“…In this month’s Clinical Orthopaedics and Related Research ® , Parola et al [4] evaluated a novel approach that moved a patient through a 4-day pathway of hip fracture treatment. They then compared a number of key outcomes (including but not limited to time from admission to surgery, complications, and readmissions) between White and non-White patients.…”

“…Hospitals and practices that don’t have pathways of this sort ought to consider developing them. The template offered by Parola et al [4] seems a thoughtful and reasonable place to begin.…”

“…We need to adopt protocols that eliminate obstacles to access by patients of varying races and standardize the treatment of all patients, regardless of race. In this study [4], the authors used a 4-day pathway to treat hip fractures and applied it strictly to all who met the inclusion criteria. But this addresses only one aspect of equity in healthcare.…”