Racial Differences in Care and Outcomes After Total Hip and Knee Arthroplasties

Abstract

Background:There is a paucity of literature on racial differences across a full total joint arthroplasty (TJA) “episode of care” and beyond. Given various incentives, the Comprehensive Care for Joint Replacement (CJR) program in the U.S. may have impacted preexisting racial differences across this care continuum. The purposes of the present study were (1) to assess trends in racial differences in care/outcome characteristics before, during, and after TJA surgery and (2) to assess if the CJR program coincided with reductions in these racial differences.Methods:This retrospective cohort study includes data on 1,483,221 TJAs (based on Medicare claims data, 2013 to 2018). Racial differences between Black and White patients were assessed for (1) preoperative characteristics (Deyo-Charlson comorbidity index, patient sex, and age), (2) characteristics during hospitalization (length of stay, blood transfusions, and combined complications), and (3) postoperative characteristics (90 and 180-day readmission rates and institutional post-acute care). Additionally, Medicare payments for each period were assessed. Racial differences (Black versus White patients) were expressed in terms of odds ratios (ORs) and 95% confidence intervals (CIs) per year. A “difference-in-differences” analysis (comparing before and after CJR implementation, with non-CJR hospitals being used as controls) estimated the association of the CJR program with changes in racial differences.Results:In both 2013 and 2018, Black patients (n = 74,390; 5.0%) were more likely than White patients to have a higher Deyo-Charlson comorbidity index (score of >0) (OR = 1.32 [95% CI = 1.28 to 1.36] and OR = 1.32 [95% CI = 1.28 to 1.37]), to require more transfusions (OR = 1.55 [95% CI = 1.49 to 1.62] and OR = 1.77 [95% CI = 1.56 to 2.01]), to be discharged to institutional post-acute care (OR = 1.40 [95% CI = 1.36 to 1.44] and OR = 1.49 [95% CI = 1.43 to 1.56]), and to be readmitted within 90 days (OR = 1.38 [95% CI = 1.32 to 1.44] and OR = 1.21 [95% CI = 1.13 to 1.29]) (p < 0.05 for all). Adjusted difference-in-differences analyses demonstrated that the CJR program coincided with reductions in racial differences in 90-day readmission (−1.24%; 95% CI, −2.46% to −0.03%) and 180-day readmission (−1.28%; 95% CI, −2.52% to −0.03%) (p = 0.044 for both).Conclusions:Racial differences persist among patients managed with TJA. The CJR program coincided with reductions in some racial differences, thus identifying bundle design as a potential novel strategy to target racial disparities.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial Disparities in Periprosthetic Joint Infections after Primary Total Joint Arthroplasty: A Retrospective Study

“…However, readmission rates among NH Black patients decreased by 24% from 2013 to 2018, narrowing racial disparities [11]. In both studies, PJI was listed among several reasons for readmission, but PJI incidence was not specifically reported [11,12]. In both studies, disparities narrowed over time.…”

“…Similarly, a retrospective analysis of national Medicare claims data on 1,483,221 TJAs performed from 2013 to 2018 found that NH Black adults were 38% more likely to have 90-day readmission compared to NH White patients in 2013. However, readmission rates among NH Black patients decreased by 24% from 2013 to 2018, narrowing racial disparities [11]. In both studies, PJI was listed among several reasons for readmission, but PJI incidence was not specifically reported [11,12].…”

“…Quality improvement (QI) projects targeting the prevention of hospital readmissions after TJA, such as the Surgical Care Improvement Project (HCIP) and the Comprehensive Care for Joint Replacement Program (CJR), have been associated with lower readmission rates for NH Black patients and the narrowing of racial disparities [11,12,53]. By reducing disparities, national QI projects focused on the provision of value-based care also have the potential to lower healthcare costs [4,54].…”

“…The extent of racial and ethnic disparities in PJI is unknown because data for distinct racial and ethnic groups in PJI incidence have been aggregated with other post-operative TJA complications [11]. For instance, an observational study of 83,887 patients in Connecticut found that Black adults were 68% more likely to have a 30-day readmission following TJA for complications including non-orthopaedic infections, deep surgical site infections, and surgical site hematomas compared to White adults [12].…”

“…It would also serve as a foundation for developing effective interventions and policies to mitigate racial disparities [17]. Baseline epidemiological data stratified by race also plays a vital role in informing modeling and cost-effectiveness studies [4,9,11].…”