Socioeconomic disadvantages may explain disparities in health care utilization after TJA
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Socioeconomic disadvantages may explain a proportion of disparities in health care utilization parameters after primary total joint arthroplasty that were previously assumed to be driven by race, according to published results.
“We need to avoid using race as a proxy for increased health care utilization or adverse outcomes and we need to start looking at the risk factors that drive those increased risks acknowledging that, depending on our geographical practice, different patient populations will have different conditions,” Nicolas S. Piuzzi, MD, director of research for the adult reconstruction section and co-director of the Musculoskeletal Research Center at the Cleveland Clinic, told Healio. “Of course, it will be associated with different race and different socioeconomical status, as well, but when we address disparities, we need to look into those things that we can provide support for and that we can implement changes in to try to improve how we are taking care of these patients.”
Methods
Piuzzi and colleagues retrospectively collected demographic data, Area Deprivation Index (ADI) data and follow-up data among patients with osteoarthritis who underwent elective primary total hip arthroplasty (n=2,345) or total knee arthroplasty (n=3,603) between November 2018 and December 2019. Researchers used multivariable regression analysis adjusted for age, gender, BMI, smoking, Charlson Comorbidity Index (CCI) and insurance to assess associations between race and length of stay of 3 or more days, non-home discharge disposition, 90-day inpatient readmission and 90-day ED admission. Researchers also explored whether the association between race and measured outcomes could be partially or completely attributable to confounding from the ADI through a mediation analysis.
Results showed 12% of patients were Black and 88% of patients were white. Black patients had higher ADI scores, slightly higher BMIs and were more likely to be current smokers at baseline in both the THA and TKA cohorts, according to researchers. Researchers also found a higher proportion of Black women in the TKA cohort compared with white women.
Associations between race, outcomes
After adjusting for age, gender, BMI, smoking, CCI and insurance, researchers noted white patients who underwent THA had lower odds of experiencing a length of stay of 3 days or more and non-home discharge. ADI partially explained 37% of the association between race and length of stay of 3 days or more, according to mediation analysis. The analysis also showed ADI partially explained 40% of the association between race and non-home discharge. Researchers observed a smaller direct association between race and length of stay of 3 days or more and non-home discharge, while race had no association with 90-day readmission or ED admission.
Results showed white patients who underwent TKA had lower odds of experiencing a length of stay of 3 days or more, non-home discharge, 90-day readmission and 90-day ED admission, after adjusting for age, gender, BMI, smoking, CCI and insurance. ADI mediated 19% of the association between race and length of stay of 3 days or more and 38% of the association between race and non-home discharge, according to mediation analysis. Although researchers found a direct association between race and length of stay of 3 days or more and non-home discharge, ADI did not mediate associations between race and 90-day readmission and ED admission.
Provide patients tools for success
Piuzzi and colleagues said these results are “a call to action to start addressing these disadvantages and not treating everybody the same.”
“We need to provide more support. We need to approach these patients differently, giving them more tools for success,” Piuzzi added.
In the joint replacement program at the Cleveland Clinic, Piuzzi noted physicians are creating a more personalized and holistic pathway for patients that includes their socioeconomic status, joint function, mobility, medical comorbidities, social support and risk factors associated with surgery. Physicians then design an individual plan for each patient that addresses comorbidities and risk factors and educates patients on what to expect before and after surgery.
“You are not doing a cookie-cutter [plan] where you do the same thing for everybody, but you are tailoring the care that you provide and the support,” Piuzzi said.
Services, such as nonemergent medical transportation and local care coordination agencies, may also allow patients access to care, follow-up and recovery, according to Piuzzi.
“I think education is a critical aspect of this, but I think that it goes beyond education,” Piuzzi said. “I think this demands setting up resources.”
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