Study reveals racial disparities in access to high-quality joint replacement care

Racial minorities have reduced access to high-quality joint replacement care, according to researchers from the University of Iowa.

The study, which reveals that African American patients are more likely than Caucasians to receive total knee arthroplasty (TKA) in low-quality hospitals, was published online in Clinical Orthopaedics and Related Research.

Xueya Cai, PhD, and colleagues used data from Medicare Provider Analysis and Review files between 2002 and 2005 to profile hospitalization information and the quality of care provided at hospitals in the United States. Quality of care, according to a Springer press release, was based on the rate of complications — including sepsis, hemorrhage, pulmonary embolism, deep vein thrombosis and severe wound infection, as well as the number of deaths — experienced in the 90 days after TKA.

The authors then examined a second cohort of 91,599 elderly TKA patient admissions in 2,842 hospitals between July 2005 and December 2005 for racial differences in access to high-, intermediate- and low-quality hospitals.

According to the results of the study, risk-adjusted postoperative mortality and complication rates varied enough across the investigated group of hospitals to conclude that hospitals could “be meaningfully categorized into quality groups.”

In analyzing the second cohort, the authors found that 8% of African American patients (4,894) were treated in high-quality hospitals, compared with 9.2% of Caucasian patients (86,705). Additionally, 14.7% of African American patients were treated in low-quality hospitals, compared with 12.7% of Caucasian patients.

The analysis, according to the release, shows African American patients undergoing TKA are less likely to be admitted to high-volume hospitals. When compared to Caucasian patients, they are more likely to be admitted to hospitals which perform fewer knee replacements.

“This racial disparity in access to high-quality arthroplasty care is a major issue, especially as arthroplasties continue to be more widely performed in both Caucasian and non-Caucasian patients with severe osteoarthritis,” the authors concluded. “More work is needed to explore African American neighborhoods, as well as social and physician-referring factors to better understand and address the issues of unequal access and quality of arthroplasties.”

Reference:

Cai X, Cram P, Vaughan-Sarrazin M. Are African American patients more likely to receive total knee arthroplasty in a low-quality hospital? Clin Orthop Relat Res. 2011. doi: 10.1007/s11999-011-2032-6

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Racial disparities in the utilization of total joint arthroplasty as a safe and effective treatment modality for lower extremity osteoarthritis have been well documented. While fewer studies exist showing racial differences in surgical outcomes, racial and ethnic minority patients appear to have a greater risk for early complications post joint arthroplasty, and there may even be a higher risk of mortality for African American patients undergoing hip replacement.

The study by Cai et al attempts to add to this growing body of literature showing that disparities exist on multiple levels for African American patients undergoing joint arthroplasty. This study used Medicare data to first derive categories of hospital quality based on risk adjusted surgical outcomes, and then to evaluate these categories amongst a separate group of Medicare beneficiaries undergoing joint replacement. Their findings that African American patients are more likely to be treated at low quality compared to high quality hospitals suggests there are barriers to African Americans' accessing quality care. This study did not account for hospital volume. Low volume hospitals have been associated with racial and ethnic minorities who are undergoing joint arthroplasty (1) and more post arthroplasty complications (2). More studies need to be done to both validate these results but to also explore potential reasons racial and ethnic minority patients have limited access to care for joint arthroplasty.

— Marissa A. Blum, MD MS
Assistant Professor of Medicine
Temple University School of Medicine
Philadelphia, PA

— Jasvinder Singh, MBBS, MPH
Birmingham VA Medical Center and Department of Medicine
University of Alabama at Birmingham
Birmingham, AL

— Said A. Ibrahim, MD, MPH
Professor of Medicine and Vice Chair
Department of Medicine
University of Pennsylvania School of Medicine
Philadelphia, PA

Reference:
SooHoo NF, Zingmond DS, Ko CY. Disparities in the utilization of high-volume hospitals for total knee replacement. J Natl Med Assoc. 2008 May; 100(5):559-64.
Singh JA, Kwoh CK, Boudreau RM, Ibrahim SA. Hospital volume and surgical outcomes after elective hip/knee arthroplasty: a risk adjusted analysis of a large regional database. Arthritis Rheum. 2011 Aug; 63(8):2531-9.