ORIGINAL ARTICLE
The Influence of Race and Ethnicity on Complications and Mortality After Orthopedic Surgery A Systematic Review of the Literature Andrew J. Schoenfeld, MD,* Renuka Tipirneni, MD,w James H. Nelson, MD,z James E. Carpenter, MD,y and Theodore J. Iwashyna, MD, PhD8
Background: The decision to perform orthopedic surgery requires substantial discretion and judgment. Similar conditions have been associated with health care disparities in other fields, but the extent of racial and ethnic disparities in orthopedics is unknown. Objective: To evaluate the quality of extant orthopedic literature on health care disparities. Research Design: This study is a systematic review. Subjects: Eligible studies reported complications and/or mortality stratified by minority group after orthopedic surgery in an American population. Measures: Queries of PubMed, Embase, Scopus, and Web of Science were performed. Included papers were abstracted regarding complication and/or mortality rates for whites and minority populations, statistical findings, and whether a health care disparity was From the *Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital; wRobert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; zDepartment of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX; yDepartment of Orthopaedic Surgery; and 8Robert Wood Johnson Clinical Scholars Program, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI. Some authors are employees of the US Federal Government and the United States Army. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States government. A.J.S. and R.T. are Robert Wood Johnson Foundation Clinical Scholars at the University of Michigan. T.J.I. is supported by the National Institutes of Health. The Robert Wood Johnson Foundation and the Department of Veterans Affairs were not directly involved in study design, data acquisition and interpretation, or manuscript preparation or review. Any opinions expressed herein do not necessarily reflect the opinions of the Robert Wood Johnson Foundation or the Department of Veterans Affairs. The authors declare no conflict of interest. Reprints: Andrew J. Schoenfeld, MD, Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI 48109. E-mail: [email protected]. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww-medical care.com. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5209-0842
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reported. Statistical associations between study characteristics and the identification of disparities were evaluated using the w2 test. Results: The literature search returned 2604 studies, of which 33 met inclusion criteria. All but 3 works dealt with spine surgery or joint replacement. Twenty-one publications (64%) documented health care disparities. Forty-four percent of efforts investigating outcomes for Hispanics and 36% of works documenting results for non-whites recorded a disparity. Investigations reporting on African Americans were significantly more likely to identify health care inequalities (77%) as compared with non-white (P = 0.02) cohorts. Conclusions: Patients from racial and ethnic minority populations seem to be at increased risk of complications and/or mortality following spine surgical or joint replacement procedures. There is insufficient evidence to support generalization to the entire orthopedic field. Studies specific to African American patients identify health care disparities at a significantly higher rate than those utilizing non-white cohorts. Key Words: disparities, race, ethnicity, African American, Hispanic, orthopedic surgery (Med Care 2014;52: 842–851)
T
he Institute of Medicine defines health care disparities as “yracial or ethnic differences in the quality of health careynot due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”1 Health care disparities have consistently been found within American medicine including cardiology, endocrinology, hematology/oncology, cardiothoracic surgery, and neurosurgery.1–6 Most recently, African American patients were found to be less likely to undergo surgery following a diagnosis of liver, lung, or pancreatic cancer,5 whereas another study reported that revascularization for peripheral vascular disease was used less frequently in African Americans before amputation.6 Yet, despite its size and importance— orthopedic surgery is a multi-billion dollar industry in the United States, with $6.7 billion in American market sales related to the performance of spine surgery alone7—there is little consensus on the prevalence or magnitude of equivalent disparities within the orthopedic field.8–12 Health care disparities may arise from a number of factors, including differences in indication, disparities in Medical Care
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procedural performance, institutional segregation, and provider bias.2,4–6,9,12 Within orthopedic surgery, the most immediate measures of quality and outcome are postoperative mortality and complications. Recent studies have estimated that health care costs may double in the event of a postoperative complication.13 Complications can also permanently diminish the chance for optimal outcome following surgery.9,12 Without a clear understanding of the extent and nature of such disparities within orthopedics, however, it is difficult to select appropriate targets for intervention. The only 2 prior reviews were limited to the fields of joint replacement9 and spine surgery12 and did not consider other important aspects of musculoskeletal medicine such as fracture care, arthroscopy, foot and ankle surgery, or orthopedic oncology. In light of these gaps, the present study intended to systematically review the extant orthopedic literature to direct future research and, if appropriate, disparity-reducing interventions. We also sought to evaluate the impact of minority status across key subfields of orthopedics, defined as spine surgery, joint replacement, and hip fracture surgery. In light of past work in other areas, we hypothesized that publications would demonstrate a negative impact of racial and ethnic minority status on mortality and complications following orthopedic surgical interventions.
METHODS Inclusion Criteria and Literature Search Studies eligible for inclusion in this review reported mortality and/or complications stratified by race or ethnicity following an orthopedic surgical procedure. Studies regarding musculoskeletal conditions where no surgery was performed, or where the performance of surgery could not be definitely determined, were excluded from the analysis. In the situation where surgical and nonsurgical cohorts were both present, only the results for those patients who received surgery were included. Included racial/ethnic designations were those of historically underserved minority populations in the United States, specifically African American/black, Hispanic/Latino, or Native American/Pacific Islander. Reports using the general classification of non-white were also included as this category typically consisted of a combination of individuals from the minority populations listed above. Because the social construct of race is applied differently in other nations and disparate historical/social circumstances may be responsible for observed inequities in health care, eligible studies had to be performed exclusively among American patients in a setting within the United States, and published in the peer-reviewed literature. The literature search was performed independently by 3 authors (A.J.S., R.T., and J.H.N.) and began with a query of the published literature cataloged in PubMed from 1966 to July 29, 2013 using a structured search algorithm (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/ MLR/A784). The search strategy was saved to provide automated updates following the conclusion of the initial query. The final update was assessed on August 31, 2013. r
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The initial PubMed search was also supplemented by a series of queries constructed using iterative combinations of the key word “disparities” with procedural terms (“orthopaedic,” “musculoskeletal,” “spine,” “arthroplasty,” “fracture,” “shoulder,” and “hand”) and racial/ethnic designations (“race,” “ethnic,” “black,” “African American,” “Hispanic,” “Latino,” and “minorities”). Similar searches were performed using Embase, Scopus, and Web of Science and in the tables of contents of Journal of Bone and Joint Surgery (American), Clinical Orthopaedics and Related Research, Spine, The Spine Journal, Journal of Orthopaedic Trauma, Foot and Ankle International, Journal of Shoulder and Elbow Surgery, Journal of Hand Surgery (American), and American Journal of Sports Medicine. The titles and abstracts of potential articles were examined and full-text articles were obtained if the study was thought to meet inclusion criteria. The complete article was then evaluated and a final determination made regarding inclusion in the study. Disagreements between reviewers were resolved by consensus. The reference lists of selected articles were manually reviewed and potentially relevant studies were acquired if they had not already been identified through the initial search algorithm.
Data Analysis and Reporting Papers identified for inclusion were individually abstracted by 2 authors (A.J.S. and R.T.) and assessed regarding study design, type of surgical intervention, study focus, use of a national dataset, total population size, total number of white and racial/ethnic minority patients, complication and/or mortality rates, whether insurance or income were considered as covariates, statistical results, and whether a health care disparity was identified. When reported in the original study, the effect size and 95% confidence interval (CI) of race and ethnicity on outcome was also recorded. Study focus was determined based on whether the role of race or ethnicity on postsurgical complications or mortality was listed as a specific aim of the investigation. Study design was defined as randomized controlled trial, prospective study, or retrospective study. Retrospective reviews of prospectively collected data were classified as retrospective in this review, regardless of their self-described design. The type of surgical intervention was categorized as spine surgery, joint replacement (hip or knee), hip fracture surgery, or other. A health care disparity was determined to be present when a study reported that racial or ethnic minority status was significantly associated with the risk of mortality or a complication(s) following the best-adjusted statistical analysis (usually multivariable logistic regression) using white patients as a referent. For works that reported multiple results at different timepoints, we decided a priori to focus on the 90-day metric, as this is the timepoint beyond which morbidity or mortality may not necessarily be attributable to surgical intervention.9 If a 90-day result was not available, the 60-day result was utilized, followed by the 30-day figure if reporting did not occur at 60 days. When reporting was limited to annual rates, metrics at 1-year postsurgery were used. Investigations that documented a health care disparity www.lww-medicalcare.com |
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in another outcome measure (eg, choice/manner of surgical intervention, length of stay, functional outcome, etc.), yet failed to show a statistically significant difference in the risk of mortality or complications between racial/ethnic groups, were recorded as negative studies for the purposes of this review. Statistical associations between the type of surgical intervention, study design, use of a national dataset and the type of racial or ethnic populations under study (eg, nonwhite, African American, Hispanic), and the detection of disparities were evaluated with the w2 test. Heterogeneity was assessed using the I2 statistic and publication bias was evaluated with Harbord’s modified test for small study effects.14 Both the literature search and data analysis were conducted in accordance with the published guidelines of the Meta-analysis of Observational Studies in Epidemiology (MOOSE)15 and Quality of Reporting of Meta-analyses (QUOROM) groups.16 Statistical testing was performed using STATA v13.0 (Stata Corp. LP, College Station, TX).
RESULTS The initial literature search returned 2605 published studies (422 from the structured search algorithm in PubMed, 935 from the iterative combination of keywords in PubMed, 348 from Embase, 547 from Scopus, 352 from Web of Science, and 1 from table of contents review). A total of 2548 investigations were excluded as duplicate citations identified in multiple searches, or following assessment of title and abstract, leaving 57 articles for full-text review (Fig. 1). After full-text review, 24 publications were further excluded (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/MLR/A785) with the remaining 33 studies meeting all inclusion criteria.
Characteristics of Disparities Studies in Orthopedic Surgery Of the included investigations, 14 involved spine surgery17–30 (Table 1), 16 addressed joint replacement,10,11,31–44 (Table 2) and hip fracture,45 lower extremity trauma,46 and tibial fracture47 were assessed in 1 study each (Table 3). The included works were published in a 20-year period between 1993 and 2013. All were retrospective observational studies with the exception of 1 that was a prospective analysis of patients treated for severe lower limb trauma.46 Eleven studies assessed complications or mortality among a heterogenous non-white cohort, whereas 22 evaluated this within African American/black populations. Mortality and complication-based outcomes were reported for Hispanics/ Latinos in 9 instances. Two studies found that Asian patients were not at elevated risk of surgical site infection after total joint replacement,33,34 whereas 1 study maintained they were at lower risk of complications.36 No works were identified that met our inclusion criteria and specifically focused on Pacific Islanders or Native Americans. Several studies reported on >1 outcome, with 12 investigating mortality and 27 documenting Z1 complications. Complications were most frequently statistically analyzed as a single category, although 6 studies specifically addressed postsurgical infection risk. Arterial injury, need for postoperative manipulation, thromboembolic events, re-
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FIGURE 1. Flow chart depicting the literature search and selection of relevant articles within the subfields of orthopedic surgery.
operation, and the development of posttraumatic psychological disorders were evaluated in 1 study each. Fifty-two percent (n = 17) of all investigations were conducted using national datasets. In addition, only 33% (n = 11) specifically focused on the role of race or ethnicity on postsurgical complications and mortality. Of these, 5 were spine surgical studies,17–19,21,24 4 involved joint replacement,10,31,35,39 and 1 each evaluated tibia47 and hip fractures.45 None of these investigations were prospective in nature.
Prevalence of Disparities Twenty-one publications (64%) documented Z1 statistically significant health care disparities in racial/ethnic minority populations. Fifty-percent (n = 7) of all spine studies and 75% (n = 12) of all investigations involving joint replacement reported a disparity. Moreover, among works conducted using a national dataset, a disparity was reported 71% of the time (n = 12), whereas 64% (n = 7) of efforts that intended to assess the association between race/ethnicity and complications or mortality identified such a finding. Among investigations studying nonelective (eg, oncology or orthopedic trauma) procedures, 50% (4 of 8) recorded a health care disparity. Overall, only 3 studies (9%) controlled for both income-related and insurance-related factors in their statistical analyses, whereas 6 (18%) addressed income alone and 12 (36%) controlled solely for insurance. Studies that specifically addressed mortality risk identified a disparity only 50% (6 of 12 publications) of the time, although Kalanithi et al25 did record an association between African American race and complex disposition [OR, 1.54 (95% CI, r
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r
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NIS 2002–2006 (spinal fusion)
Cahill et al26
White White
Non-white Black, Hispanic
Black Non-white (black, other)
Complications
Non-white (black, Hispanic, Asian, Pacific Islander)
White
White
White
White
White
Non-white
African American
White
Black
Complications
Complications and “complex disposition” (mortality or discharge to location other than home) Complications
White
Black
White
White
White
Non-whites at increased risk of complications following anterior cervical fusion [OR, 1.24 (95% CI, 1.04, 1.47)], thoracic fusion [OR, 1.58 (95% CI, 1.21, 2.07)], and lumbar fusion [OR, 1.35 (95% CI, 1.19, 1.54)] Black patients at increased risk of complications [OR, 1.9 (95% CI, 1.3, 2.7)] No significant difference in the rate of complications between non-white and white patients (P = 0.12)
No significant association between race and the rate of complications (P = 0.8277). African Americans more likely to have a complex disposition [OR, 1.54 (95% CI, 1.17, 2.03)]
Non-white race was not associated with an increased risk of mortality [HR, 1.1 (95% CI 0.8, 1.5)] Black patients were at an increased risk of mortality as compared with whites [OR, 1.57 (95% CI, 1.16, 2.12) P < 0.001]. Hispanics were not at increased risk of mortality [OR, 1.07 (95% CI, 0.63, 1.82) P = 0.8]
No significant association identified between black race and the rate of complications (P = 0.39) or mortality (P = 0.78) In the spine surgery cohort, no association was found between race and survival. Survival HR (for whites) 0.73, (95% CI, 0.5, 1.07)
Non-whites were at increased risk of mortality compared with whites [OR, 1.6 (95% CI, 1.1, 2.4) P = 0.02]. Black patients were also at increased risk of mortality [OR, 2.1, (95% CI, 1.25, 3.6) P = 0.005]. Neither non-whites [OR, 1.0 (95% CI, 0.8, 1.3) P = 0.9] or blacks [OR, 0.8 (95% CI, 0.6, 1.2) P = 0.3] were at increased risk of complications Black patients were at increased risk of pulmonary embolism [OR, 1.8 (95% CI, 1.3, 2.4) P < 0.0005]
African-Americans were at an increased risk of postoperative complications at 90 d after index procedure [OR, 1.611 (95% CI, 1.116, 2.326) P = 0.04] Non-whites were not at increased risk of complications as compared with whites [OR (for white patients) 0.48 (95% CI, 0.21, 1.14) P = 0.09]
Findings
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
Yes
Disparity Identified Other Finding
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(Continued )
N/A
N/A
N/A
Black patients and Hispanic patients less likely to receive anterior cervical surgery N/A
N/A
Whites more likely to receive surgery than black patients N/A
N/A
Non-White patients had shorter hospital LOS.
African Americans had longer hospital LOS and were prescribed fewer medications White patients more likely to receive surgery
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Patil et al27 NIS 1993–2002 (spinal cord tumor) Patil et al28 NIS 1993–2002 (spinal metastases)
NIS 1993–2002 (spondylolisthesis)
Kalanithi et al25
Complications (thromboembolic events) Schoenfeld Spine Patients Outcomes Mortality, complications 21 et al Research Trial (SPORT) Surveillance, Mortality Cahill Epidemiology, and et al22 End Results (SEER) database (breast cancer metastases) Partners’ Research Mortality Harris 23 Patient Data Registry et al NIS 1992–2005 (anterior Mortality Alosh cervical surgery) et al24
NIS 2002–2009
Fineberg et al20
Mortality, complications
Non-white (African American, Hispanic, Asian/Pacific Islander, Native American) Non-white, black
African American
Comparison Group*
Schoenfeld National Trauma Databank et al19
Nationwide Inpatient Complications Sample (NIS) 1998–2007 (idiopathic scoliosis)
Nuno et al18
Complications
Outcome(s) Evaluated
Medicaid data of Thomson Reuter’s MarketScan
Data Source
Lad et al17
References
Minority Population(s) Studied*
TABLE 1. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Spine Surgery
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DISCUSSION
*Reported as characterized by the authors of the study. CI indicates confidence interval; LOS, length of stay; OR, odds ratio.
White Black Complications (reoperation) Ciol et al30
1.17, 2.03)], a classification that included in-hospital death as well as discharge to a location other than home. Interestingly, only 44% (4 of 9) of efforts providing outcomes for Hispanics/Latinos and 36% (4 of 11) of works documenting results for non-white cohorts encountered a disparity. In contrast, 77% (17 of 22) of investigations reporting on African Americans/blacks were able to identify Z1 health care disparities in the risk of postoperative complications or mortality (Fig. 2). The largest effect size for mortality was encountered in the work of Schoenfeld et al,19 where black patients were found to be at >2-fold increased risk of mortality [OR, 2.1 (95% CI, 1.25, 3.6)] following spinal trauma as compared with whites. Escalante and Beardmore43 published the largest effect size for a complication, finding that Hispanic patients were at >2 times the risk of complications [RR, 2.86 (95% CI, 1.43, 5.56)] when compared with a non-Hispanic cohort undergoing total knee arthroplasty. Statistical testing indicated that there was no significant association between the type of procedure under study (P = 0.3), study focus (P = 1.0), or use of a national dataset (P = 0.4) and the identification of disparities. Investigations reporting on African American populations encountered disparities at a significantly higher rate than those examining non-white (P = 0.02) cohorts, whereas a borderline association (P = 0.08) existed when compared with studies examining Hispanic patients. The I2 for studies reporting outcomes using an effect size and 95% CI was 82.5%, indicating that substantial heterogeneity was present and pooled meta-analysis was determined to be inappropriate. The test for small study effects was not significant (P = 0.1), demonstrating a low likelihood of publication bias.
Black patients were at decreased risk of reoperation [RR, 0.56 (95% CI, 0.44, 0.72)]
N/A No White
Duke University Medical Center/ Durham Regional Hospital Medicare Claims Data (1985) Friedman et al29
Complications (infection)
Non-white
Multivariable analysis found non-white race was not associated with the risk of infection [OR, 2.5 (95% CI, 0.88, 7.1) P = 0.08]
Disparity Identified Findings Comparison Group* Data Source References
Outcome(s) Evaluated
Minority Population(s) Studied*
TABLE 1. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Spine Surgery (continued)
Other Finding
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Since the civil rights movement of the 1960s, the extent of health care disparities within American medicine has been reduced, yet evidence of inequality persists as demonstrated in several works addressing disparate outcomes between minorities and white patients.1–6,48 This issue has been incompletely explored within the orthopedic discipline.8,9 We performed a systematic review of the literature, identifying 33 publications since 1993 (Tables 1–3) that met inclusion criteria. Sixty-four percent of these identified Z1 health care disparities related to mortality or postoperative complications in non-white, African American, or Hispanic populations. Racial and ethnic minorities seem to be at elevated risk of complications and mortality following spine surgery or joint replacement. There was insufficient evidence—positive or negative—to support conclusions regarding other aspects of orthopedic surgery, or to generalize findings to the field in its entirety. Studies specific to African American patients were more likely to identify health care disparities compared with those specific to Hispanics or efforts that amalgamated results for individuals from different minorities into a single non-white classification. Of equal importance, we were only able to identify 11 studies (33% of the total) that focused on identifying orthopedic health care r
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NIS 1998–2007
Poultsides et al32
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California Office of Statewide Health Planning and Development Veterans Administration Surgical Quality Improvement Program (VASQIP, 1996–2003) California Office of Statewide Health Planning and Development VASQIP (1996–2000)
SooHoo et al36
Mortality, complications (infection) Mortality
Medicare Claims Data (1995–1996)
Mahomed et al41
Black
Black
Black, Hispanic Black, Hispanic
Complications
Medicare Claims Data (2000)
Black, Hispanic
Complications
White
White
White
White
White
African Non–African American American (99% white)
White
White
White
White
Complications (arterial injury)
Black, Hispanic, Asian
Black, Hispanic, Asian Black, Hispanic
Black, Hispanic, Asian
White
White
White
White
Comparison Group*
Black race associated with increased risk of mortality [OR, 1.48 (95% CI, 1.03, 2.11)]
Black race associated with higher rate of pulmonary embolism [OR, 1.74 (95% CI, 1.36, 2.23) P < 0.001]. Hispanic ethnicity associated with increased risk of infection [OR, 1.21 (95% CI, 1.03, 1.43) P = 0.02] THA cohort: neither black race nor Hispanic ethnicity were associated with an increased risk of complications TKA cohort: black patients had a higher risk of noninfectionrelated complications [OR, 1.5 (95% CI, 1.08, 2.1) P = 0.02] and infection-related complications [OR, 1.42 (95% CI, 1.06, 1.9) P = 0.02]. Hispanic patients were at increased risk of infection [OR, 1.64 (95% CI, 1.08, 2.49) P = 0.02] Blacks had a tendency toward higher mortality [rate ratio, 1.4 (95% CI, 1.0, 1.8)] and deep infection [rate ratio, 1.5 (95% CI, 1.0, 2.1).
Black patients had increased risk of complications compared with whites [OR, 1.19 (95% CI, 1.05, 1.35) P = 0.007]. Hispanics had lower risk of complications [OR, 0.75 (95% CI, 0.67, 0.85) P < 0.001] African Americans at increased risk of arterial injury during arthroplasty procedures [OR, 2.5 (95% CI, 1.2, 5.3) P = 0.02]
Black race associated with increased risk of complications [OR, 1.2 (95% CI, 1.07, 1.35)]. Black race associated with increased risk of mortality [OR, 1.65 (95% CI, 1.33, 2.05)]w Black race [OR, 1.39 (95% CI, 1.22, 1.58) P < 0.001] and Hispanic ethnicity [OR, 1.5 (95% CI, 1.28, 1.75) P < 0.001] associated with increased risk of infection Black race was not associated with risk of infection [OR, 1.23 (95% CI, 0.88, 1.71) P = 0.223]. Hispanic ethnicity associated with a decreased risk of infection [OR, 0.69 (95% CI, 0.49, 0.98) P = 0.038] No significant risk of infection associated with black race [OR, 0.63 (95% CI, 0.29, 1.34)] or Hispanic ethnicity [OR, 1.52 (95% CI, 0.9, 2.57)] Black patients at an increased risk of necessitating a manipulation [OR, 2.13 (95% CI, 1.46, 3.11)]. No association noted for Hispanic ethnicity [OR, 1.4 (95% CI, 0.35, 5.54)]
Black race was associated with a higher complication rate [OR, 1.678 (95% CI, 1.346, 2.092) P < 0.0001] No association between race and complications (P = 0.83) or mortality (P = 0.74)
Findings
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
Disparity Identified
Blacks had lower rates of primary and revision total knee replacement Black patients less likely to receive primary or revision THA (Continued )
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Increased 5 y revision rates for African Americans N/A
N/A
Other Findings
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Mahomed et al40
Ibrahim et al39
SooHoo et al38
Abularrage et al37
Multicenter Study (2004–2010)
Complications (infection) after THA Complications (need for postoperative manipulation) after TKA Complications
Namba et al34 Kaiser Permanente Registry (2001–2009)
Springer et al35
Complications (infection) after TKA
Black, Hispanic
Black
Mortality, complications Complications (infection)
African American
Black
Mortality, complications
Complications
Namba et al33 Kaiser Permanente Registry (2001–2009)
Adelani et al31
Pennsylvania Health Care Cost Containment Council NIS 1998–2005
NSQIP (2005–2010)
Data Source
Minority Population Studied*
Blum et al10
Pugely et
al11
References
Outcome(s) Evaluated
TABLE 2. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Total Joint Arthroplasty
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Medicare Claims Data (1983–1985)
Mortality
Non-white
Non-Hispanic (all complications occurred in nonHispanic whites) White
White
Non-white Hispanic
White
Comparison Group*
Non-white
Minority Population Studied*
Non-white race was not associated with mortality [HR, 1.01 (95% CI, 0.59, 1.73)]
TKA cohort: non-whites at increased risk of complications [OR (whites), 0.793 (95% CI, 0.666, 0.943)] Hispanic patientsz were at a significantly increased risk of wound healing complications [RR, 2.86 (95% CI, 1.43, 5.56)]
THA cohort: no impact of race on complications
Findings
No
Yes
Yes
No
Disparity Identified
N/A
Non-white patients had longer LOS
Non-white patients had longer LOS
Other Findings
r
Non-white
Lower Extremity Complications (postinjury Assessment psychological disorder) after Project severe lower limb injury
McCarthy et al46
Neuman et al45
Temple Mortality, complications Non-white University (infection) after tibia fracture (black, Hospital Hispanic, trauma dataset other) Medicare Mortality after hip fracture Black 2002–2006 (NY, IL, TX)
Piposar et al47
Outcome(s) Evaluated
Non-whites were more likely to screen positive for psychological disorder [OR, 1.55 (95% CI, 1.11, 2.16)]
Black surgical patients had a lower rate of survival as compared with whites (0.779 vs. 0.799, P < 0.001)
White
White
No increased risk of infection among minority patients [OR, 1.2 (95% CI, 0.44, 3.31) P = 1.0]. No increased rate of mortality among minority patients (P = 0.2)
White
Findings
Yes
Yes
No
Disparity Identified
Black patients more likely to receive nonoperative treatment N/A
N/A
Other Finding
Data Source
Medical Care
References
Minority Population(s) Comparison Studied Group
TABLE 3. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Other Orthopedic Procedures
*Reported as characterized by the authors of the study. w Data reported in the table reflect those documented in the text of the paper.26 Different figures, however, are presented in the article’s Table 3, specifically: OR, 1.70 (95% CI, 1.37, 2.10) for mortality and OR, 1.54 (95% CI, 1.42, 1.68) for complications.26 z In this study, the referent group was a non-Hispanic cohort and 61% (225/367) of the population underwent joint replacement, with the remainder receiving other types of orthopedic interventions. All 13 complications in nonHispanic patients, however, occurred in non-Hispanic whites. CI indicates confidence interval; LOS, length of stay; HR, hazard ratio; OR, odds ratio; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Whittle et al44
Complications
VASQIP and VA inpatient Complications medical dataset (1991–1997)
Data Source
Escalante and Rancho Los Amigos Arthritis Unit Beardmore43z
Weaver et al42
References
Outcome(s) Evaluated
TABLE 2. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Total Joint Arthroplasty (continued)
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FIGURE 2. Forest plot depicting the population size (gray box), effect size (ES), and 95% confidence intervals (CI) of non-white or African American race on mortality or complications after orthopedic surgery. Only those studies (n = 25) that reported outcomes using ES and 95% CI for non-white or African American patients are included in the Forest plot.
disparities in minority populations and 3 that performed appropriate controls for the effect of health insurance and socioeconomic status. To the best of our knowledge, only 2 prior works have conducted systematic reviews of health care inequality in orthopedics.9,12 Nwachukwu et al9 cataloged 9 studies that considered disparities in outcome following joint replacement. These authors concluded that minority patients were at increased risk of complications after total hip or knee procedures, although the strongest association between race/ ethnicity and outcome was with length of hospital stay. Schoenfeld et al12 surveyed the spine literature, including 11 articles in their systematic review. This group also performed a meta-analysis of 4 works and reported that non-white patients were at increased risk of unfavorable outcomes [risk ratio, 1.3 (95% CI, 1.2, 1.4), P = 0.003] after spine surgery.12 Neither of these efforts, however, focused their reviews on complications or mortality, nor did they deconstruct results by race or ethnicity. In the current investigation, health care disparities were identified at a significantly higher rate in studies that reported results for African Americans (77%) as opposed to those that grouped disparate racial and ethnic minorities into the heterogeneous classification of non-white (36%, P = 0.02), highlighting the importance of examining outcomes by meaningful racial or ethnic definitions. A borderline difference (P = 0.08), likely due to the limited number of publications under consideration, was also appreciated when comparing studies involving African Americans to those that assessed outcomes among Hispanics. As several scholars point out, numerous variables play a role in influencing r
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health care inequality including socioeconomic status, attitudes toward health care use, and trust of the health care system.1,3,9,12,21,48 It should be noted that none of the works included in this review sought to explain the underlying factors responsible for identified disparities. Some explanatory factors may be masked by the social and nonscientific constructs of race or ethnicity, particularly when such classifications encompass multiple heterogeneous cohorts1,12,48 or include Hispanic and Latino patients whose outcomes may be influenced to a greater extent by acculturation, or neighborhood factors, than other minority groups.49 For example, the non-white group in many studies is not necessarily representative of underserved, or medically disadvantaged, minority populations. Similarly, the designation of Hispanic/Latino is a broad category that can be applied to a diverse population representing different countries of origin, immigration status, English language facility, cultural values, and socioeconomic class.49 When grouping individuals of diverse background into a single stratum, the result may be a bias toward the population mean, thus underrepresenting disparities that may exist within certain subsets. This systematic review also identified substantial limitations in the current state of health care disparities research in orthopedics. The overwhelming majority of studies included in this review were retrospective in nature and only 33% specifically intended to investigate the influence of race or ethnicity on outcomes after orthopedic surgery. As a result, there is a large potential for many of these works to be confounded by underlying biases, or underpowered to detect differences among the minority patients in their cohort www.lww-medicalcare.com |
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(Fig. 2). Furthermore, 91% of included studies addressed spinal surgery or joint replacement and none examined the subspecialties of foot and ankle surgery, hand surgery, shoulder surgery, or sports medicine. Although we identified 11 articles investigating the role of race and ethnicity on outcomes following hip fracture, 10 had to be excluded (Appendix 2, Supplemental Digital Content 2, http://links. lww.com/MLR/A785). Thus, although this review summarizes findings within the published orthopedic literature, the results suggest that we simply do not know the current state of disparities for the discipline as a whole. Our work itself also has certain limitations, beyond those imposed by the state of the literature, including the prospect of publication bias. We maintain that the potential for publication bias to confound our results is less likely, however, given the result of our test for small study effects (P = 0.1). This investigation suggests crucial gaps in the orthopedic literature, despite the field’s importance to American health care. First, there is a paucity of data regarding the impact of minority status on orthopedic surgical outcomes for several subspecialties within the field, including sports medicine, foot and ankle surgery, upper extremity surgery, orthopedic trauma, and oncology. This review might serve as a call for qualified health services researchers to explore disparities in these arenas. Second, researchers should report findings by racial or ethnic group rather than consolidate patients into a single category of non-white, as such a practice underestimates the presence of health care inequities. Third, investigations conducting research on minority populations should also adjust for the effect of income and insurance status on study outcomes. Finally, relatively few works have been specifically designed to enable accurate determinations regarding health care inequalities in orthopedic surgery and none have shed light on the underlying reasons for observed disparities. Furthermore, at present, no prospective investigation has been conducted with the intent of evaluating the impact of race or ethnicity on adverse outcomes after orthopedic interventions. A large multicenter prospective effort could control for many of the socioeconomic, cultural, and health system–based factors that might confound retrospective observational studies. Supplemented by appropriate simulated patient and randomized vignette studies to isolate different mechanisms amenable to intervention, such work is necessary to identify the current roles that race and ethnicity play in modulating the risk of mortality and complications after orthopedic surgery. One might ask, what are the implications of these results for the practicing clinician? We would suggest, at a minimum, that our findings highlight the fact that disparities in acute postsurgical outcomes currently exist within the field of orthopedic surgery. To mitigate their potential, it is imperative that physicians administer culturally competent care to patients and be vigilant regarding practices that may have an adverse impact on outcomes for individuals from disadvantaged backgrounds. To comprehensively address this issue, it is necessary that the orthopedic practitioner not only tailor interventions to the preoperative and postoperative periods, but also in the setting of the index hospitalization itself.
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REFERENCES 1. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Int Med. 2006;21:667–669. 2. Mukherjee D, Patil CG, Todnem N, et al. Racial disparities in Medicaid patients after brain tumor surgery. J Clin Neurosci. 2013; 20:57–61. 3. Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Int Med. 2008;23:654–671. 4. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–626. 5. Revels SL, Banerjee M, Yin H, et al. Racial disparities in surgical resection and survival among elderly patients with poor prognosis cancer. J Am Coll Surg. 2013;216:312–319. 6. Holman KH, Henke PK, Dimick JB, et al. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54:420–426. 7. Mendenhall S. 2012 Spinal industry update. Orthop Netw News. 2012;23:3–6. 8. Skinner J, Weinstein JN, Sporer SM, et al. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359. 9. Nwachukwu BU, Kenny AD, Losina E, et al. Complications for racial and ethnic minority groups after total hip and knee replacement: a review of the literature. J Bone Joint Surg Am. 2010;92:338–345. 10. Blum MA, Singh JA, Lee GC, et al. Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database. Arth Care Res. 2013;65:414–420. 11. Pugely AJ, Martin CT, Gao Y, et al. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95:193–199. 12. Schoenfeld AJ, Sieg RN, Li G, et al. Outcomes after spine surgery among racial/ethnic minorities: a meta-analysis of the literature. Spine J. 2011;11:381–388. 13. Parker SL, Shau DN, Mendenhall SK, et al. Factors influencing 2-year health care costs in patients undergoing revision lumbar fusion procedures. J Neurosurg Spine. 2012;16:323–328. 14. Sterne JAC. Meta-Analysis in STATA: An Updated Collection From the STATA Journal. College Station, TX: STATA Press; 2009. 15. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283:2008–2012. 16. Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999;354:1896–1900. 17. Lad SP, Bagley JH, Kenney KT, et al. Racial disparities in outcomes of spinal surgery for lumbar stenosis. Spine. 2013;38:927–935. 18. Nuno M, Drazin DG, Acosta FL Jr. Differences in treatments and outcomes for idiopathic scoliosis patients treated in the United States from 1998 to 2007: impact of socioeconomic variables and ethnicity. Spine J. 2013;13:116–123. 19. Schoenfeld AJ, Belmont PJ Jr, See AA, et al. Patient demographics, insurance status, race, and ethnicity as predictors of morbidity and mortality after spine trauma: a study using the National Trauma Data Bank. Spine J. 2013;13:1766–1773. 20. Fineberg SJ, Oglesby M, Patel AA, et al. The incidence and mortality of thromboembolic events in lumbar spine surgery. Spine. 2013;38: 1154–1159. 21. Schoenfeld AJ, Lurie JD, Zhao W, et al. The effect of race on outcomes of surgical or nonsurgical treatment of patients in the Spine Patient Outcomes Research Trial (SPORT). Spine. 2012;37:1505–1515. 22. Cahill KS, Chi JH, Day AL, et al. Trends in survival after surgery for breast cancer metastatic to the brain and spinal column in medicare patients: a population-based analysis. Neurosurgery. 2011;68:705–713; discussion 713. 23. Harris MB, Reichmann WM, Bono CM, et al. Mortality in elderly patients after cervical spine fractures. J Bone Joint Surg Am. 2010;92:567–574. 24. Alosh H, Riley LH III, Skolasky RL. Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and r
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25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.
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in-hospital mortality: an examination of United States trends from 1992 to 2005. Spine. 2009;34:1956–1962. Kalanithi PS, Patil CG, Boakye M. National complication rates and disposition after posterior lumbar fusion for acquired spondylolisthesis. Spine. 2009;34:1963–1969. Cahill KS, Chi JH, Day A, et al. Prevalence, complications, and hospital charges associated with use of bone-morphogenetic proteins in spinal fusion procedures. JAMA. 2009;302:58–66. Patil CG, Patil TS, Lad SP, et al. Complications and outcomes after spinal cord tumor resection in the United States from 1993 to 2002. Spinal Cord. 2008;46:375–379. Patil CG, Lad SP, Santarelli J, et al. National inpatient complications and outcomes after surgery for spinal metastasis from 1993-2002. Cancer. 2007;110:625–630. Friedman ND, Sexton DJ, Connelly SM, et al. Risk factors for surgical site infection complicating laminectomy. Infect Cont Hosp Epi. 2007; 28:1060–1065. Ciol MA, Deyo RA, Kreuter W, et al. Characteristics in Medicare beneficiaries associated with reoperation after lumbar spine surgery. Spine. 1994;19:1329–1334. Adelani MA, Archer KR, Song Y, et al. Immediate complications following hip and knee arthroplasty: does race matter? J Arthroplasty. 2013;28:732–735. Poultsides LA, Ma Y, Della Valle AG, et al. In-hospital surgical site infections after primary hip and knee arthroplasty–incidence and risk factors. J Arthroplasty. 2013;28:385–389. Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013;95:775–782. Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br. 2012;94:1330–1338. Springer BD, Odum SM, Nagpal VS, et al. Is socioeconomic status a risk factor for stiffness after total knee arthroplasty? A multicenter casecontrol study. Orthop Clin North Am. 2012;43:e1–e7. Soohoo NF, Farng E, Lieberman JR, et al. Factors that predict shortterm complication rates after total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2363–2371.
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37. Abularrage CJ, Weiswasser JM, Dezee KJ, et al. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg. 2008;47:803–807; discussion 807-808. 38. SooHoo NF, Lieberman JR, Ko CY, et al. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480–485. 39. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arth Rheumatol. 2005;52:3143–3151. 40. Mahomed NN, Barrett J, Katz JN, et al. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am. 2005;87:1222–1228. 41. Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2003;85-A:27–32. 42. Weaver F, Hynes D, Hopkinson W, et al. Preoperative risks and outcomes of hip and knee arthroplasty in the Veterans Health Administration. J Arthroplasty. 2003;18:693–708. 43. Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol. 1995;22:1844–1851. 44. Whittle J, Steinberg EP, Anderson GF, et al. Mortality after elective total hip arthroplasty in elderly Americans. Age, gender, and indication for surgery predict survival. Clin Orthop Relat Res. 1993;295: 119–126. 45. Neuman MD, Fleisher LA, Even-Shoshan O, et al. Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities. Med Care. 2010;48:314–320. 46. McCarthy ML, MacKenzie EJ, Edwin D, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003;85-A:1689–1697. 47. Piposar J, Fowler JR, Gaughan JP, et al. Race may not affect [correct] outcomes in operatively treated tibia fractures. Clin Orthop Relat Res. 2012;470:1513–1517. 48. Kirby JB, Taliaferro G, Zuvekas SH. Explaining racial and ethnic disparities in health care. Med Care. 2006;44:I64–I72. 49. Franzini L, Ribble JC, Kiddie AM. Understanding the Hispanic paradox. Ethn Dis. 2001;11:496–518.
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The Influence of Race and Ethnicity on Complications and Mortality After Orthopedic Surgery A Systematic Review of the Literature Andrew J. Schoenfeld, MD,* Renuka Tipirneni, MD,w James H. Nelson, MD,z James E. Carpenter, MD,y and Theodore J. Iwashyna, MD, PhD8
Background: The decision to perform orthopedic surgery requires substantial discretion and judgment. Similar conditions have been associated with health care disparities in other fields, but the extent of racial and ethnic disparities in orthopedics is unknown. Objective: To evaluate the quality of extant orthopedic literature on health care disparities. Research Design: This study is a systematic review. Subjects: Eligible studies reported complications and/or mortality stratified by minority group after orthopedic surgery in an American population. Measures: Queries of PubMed, Embase, Scopus, and Web of Science were performed. Included papers were abstracted regarding complication and/or mortality rates for whites and minority populations, statistical findings, and whether a health care disparity was From the *Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital; wRobert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; zDepartment of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX; yDepartment of Orthopaedic Surgery; and 8Robert Wood Johnson Clinical Scholars Program, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI. Some authors are employees of the US Federal Government and the United States Army. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States government. A.J.S. and R.T. are Robert Wood Johnson Foundation Clinical Scholars at the University of Michigan. T.J.I. is supported by the National Institutes of Health. The Robert Wood Johnson Foundation and the Department of Veterans Affairs were not directly involved in study design, data acquisition and interpretation, or manuscript preparation or review. Any opinions expressed herein do not necessarily reflect the opinions of the Robert Wood Johnson Foundation or the Department of Veterans Affairs. The authors declare no conflict of interest. Reprints: Andrew J. Schoenfeld, MD, Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI 48109. E-mail: [email protected]. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.lww-medical care.com. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5209-0842
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reported. Statistical associations between study characteristics and the identification of disparities were evaluated using the w2 test. Results: The literature search returned 2604 studies, of which 33 met inclusion criteria. All but 3 works dealt with spine surgery or joint replacement. Twenty-one publications (64%) documented health care disparities. Forty-four percent of efforts investigating outcomes for Hispanics and 36% of works documenting results for non-whites recorded a disparity. Investigations reporting on African Americans were significantly more likely to identify health care inequalities (77%) as compared with non-white (P = 0.02) cohorts. Conclusions: Patients from racial and ethnic minority populations seem to be at increased risk of complications and/or mortality following spine surgical or joint replacement procedures. There is insufficient evidence to support generalization to the entire orthopedic field. Studies specific to African American patients identify health care disparities at a significantly higher rate than those utilizing non-white cohorts. Key Words: disparities, race, ethnicity, African American, Hispanic, orthopedic surgery (Med Care 2014;52: 842–851)
T
he Institute of Medicine defines health care disparities as “yracial or ethnic differences in the quality of health careynot due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”1 Health care disparities have consistently been found within American medicine including cardiology, endocrinology, hematology/oncology, cardiothoracic surgery, and neurosurgery.1–6 Most recently, African American patients were found to be less likely to undergo surgery following a diagnosis of liver, lung, or pancreatic cancer,5 whereas another study reported that revascularization for peripheral vascular disease was used less frequently in African Americans before amputation.6 Yet, despite its size and importance— orthopedic surgery is a multi-billion dollar industry in the United States, with $6.7 billion in American market sales related to the performance of spine surgery alone7—there is little consensus on the prevalence or magnitude of equivalent disparities within the orthopedic field.8–12 Health care disparities may arise from a number of factors, including differences in indication, disparities in Medical Care
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procedural performance, institutional segregation, and provider bias.2,4–6,9,12 Within orthopedic surgery, the most immediate measures of quality and outcome are postoperative mortality and complications. Recent studies have estimated that health care costs may double in the event of a postoperative complication.13 Complications can also permanently diminish the chance for optimal outcome following surgery.9,12 Without a clear understanding of the extent and nature of such disparities within orthopedics, however, it is difficult to select appropriate targets for intervention. The only 2 prior reviews were limited to the fields of joint replacement9 and spine surgery12 and did not consider other important aspects of musculoskeletal medicine such as fracture care, arthroscopy, foot and ankle surgery, or orthopedic oncology. In light of these gaps, the present study intended to systematically review the extant orthopedic literature to direct future research and, if appropriate, disparity-reducing interventions. We also sought to evaluate the impact of minority status across key subfields of orthopedics, defined as spine surgery, joint replacement, and hip fracture surgery. In light of past work in other areas, we hypothesized that publications would demonstrate a negative impact of racial and ethnic minority status on mortality and complications following orthopedic surgical interventions.
METHODS Inclusion Criteria and Literature Search Studies eligible for inclusion in this review reported mortality and/or complications stratified by race or ethnicity following an orthopedic surgical procedure. Studies regarding musculoskeletal conditions where no surgery was performed, or where the performance of surgery could not be definitely determined, were excluded from the analysis. In the situation where surgical and nonsurgical cohorts were both present, only the results for those patients who received surgery were included. Included racial/ethnic designations were those of historically underserved minority populations in the United States, specifically African American/black, Hispanic/Latino, or Native American/Pacific Islander. Reports using the general classification of non-white were also included as this category typically consisted of a combination of individuals from the minority populations listed above. Because the social construct of race is applied differently in other nations and disparate historical/social circumstances may be responsible for observed inequities in health care, eligible studies had to be performed exclusively among American patients in a setting within the United States, and published in the peer-reviewed literature. The literature search was performed independently by 3 authors (A.J.S., R.T., and J.H.N.) and began with a query of the published literature cataloged in PubMed from 1966 to July 29, 2013 using a structured search algorithm (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/ MLR/A784). The search strategy was saved to provide automated updates following the conclusion of the initial query. The final update was assessed on August 31, 2013. r
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The initial PubMed search was also supplemented by a series of queries constructed using iterative combinations of the key word “disparities” with procedural terms (“orthopaedic,” “musculoskeletal,” “spine,” “arthroplasty,” “fracture,” “shoulder,” and “hand”) and racial/ethnic designations (“race,” “ethnic,” “black,” “African American,” “Hispanic,” “Latino,” and “minorities”). Similar searches were performed using Embase, Scopus, and Web of Science and in the tables of contents of Journal of Bone and Joint Surgery (American), Clinical Orthopaedics and Related Research, Spine, The Spine Journal, Journal of Orthopaedic Trauma, Foot and Ankle International, Journal of Shoulder and Elbow Surgery, Journal of Hand Surgery (American), and American Journal of Sports Medicine. The titles and abstracts of potential articles were examined and full-text articles were obtained if the study was thought to meet inclusion criteria. The complete article was then evaluated and a final determination made regarding inclusion in the study. Disagreements between reviewers were resolved by consensus. The reference lists of selected articles were manually reviewed and potentially relevant studies were acquired if they had not already been identified through the initial search algorithm.
Data Analysis and Reporting Papers identified for inclusion were individually abstracted by 2 authors (A.J.S. and R.T.) and assessed regarding study design, type of surgical intervention, study focus, use of a national dataset, total population size, total number of white and racial/ethnic minority patients, complication and/or mortality rates, whether insurance or income were considered as covariates, statistical results, and whether a health care disparity was identified. When reported in the original study, the effect size and 95% confidence interval (CI) of race and ethnicity on outcome was also recorded. Study focus was determined based on whether the role of race or ethnicity on postsurgical complications or mortality was listed as a specific aim of the investigation. Study design was defined as randomized controlled trial, prospective study, or retrospective study. Retrospective reviews of prospectively collected data were classified as retrospective in this review, regardless of their self-described design. The type of surgical intervention was categorized as spine surgery, joint replacement (hip or knee), hip fracture surgery, or other. A health care disparity was determined to be present when a study reported that racial or ethnic minority status was significantly associated with the risk of mortality or a complication(s) following the best-adjusted statistical analysis (usually multivariable logistic regression) using white patients as a referent. For works that reported multiple results at different timepoints, we decided a priori to focus on the 90-day metric, as this is the timepoint beyond which morbidity or mortality may not necessarily be attributable to surgical intervention.9 If a 90-day result was not available, the 60-day result was utilized, followed by the 30-day figure if reporting did not occur at 60 days. When reporting was limited to annual rates, metrics at 1-year postsurgery were used. Investigations that documented a health care disparity www.lww-medicalcare.com |
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in another outcome measure (eg, choice/manner of surgical intervention, length of stay, functional outcome, etc.), yet failed to show a statistically significant difference in the risk of mortality or complications between racial/ethnic groups, were recorded as negative studies for the purposes of this review. Statistical associations between the type of surgical intervention, study design, use of a national dataset and the type of racial or ethnic populations under study (eg, nonwhite, African American, Hispanic), and the detection of disparities were evaluated with the w2 test. Heterogeneity was assessed using the I2 statistic and publication bias was evaluated with Harbord’s modified test for small study effects.14 Both the literature search and data analysis were conducted in accordance with the published guidelines of the Meta-analysis of Observational Studies in Epidemiology (MOOSE)15 and Quality of Reporting of Meta-analyses (QUOROM) groups.16 Statistical testing was performed using STATA v13.0 (Stata Corp. LP, College Station, TX).
RESULTS The initial literature search returned 2605 published studies (422 from the structured search algorithm in PubMed, 935 from the iterative combination of keywords in PubMed, 348 from Embase, 547 from Scopus, 352 from Web of Science, and 1 from table of contents review). A total of 2548 investigations were excluded as duplicate citations identified in multiple searches, or following assessment of title and abstract, leaving 57 articles for full-text review (Fig. 1). After full-text review, 24 publications were further excluded (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/MLR/A785) with the remaining 33 studies meeting all inclusion criteria.
Characteristics of Disparities Studies in Orthopedic Surgery Of the included investigations, 14 involved spine surgery17–30 (Table 1), 16 addressed joint replacement,10,11,31–44 (Table 2) and hip fracture,45 lower extremity trauma,46 and tibial fracture47 were assessed in 1 study each (Table 3). The included works were published in a 20-year period between 1993 and 2013. All were retrospective observational studies with the exception of 1 that was a prospective analysis of patients treated for severe lower limb trauma.46 Eleven studies assessed complications or mortality among a heterogenous non-white cohort, whereas 22 evaluated this within African American/black populations. Mortality and complication-based outcomes were reported for Hispanics/ Latinos in 9 instances. Two studies found that Asian patients were not at elevated risk of surgical site infection after total joint replacement,33,34 whereas 1 study maintained they were at lower risk of complications.36 No works were identified that met our inclusion criteria and specifically focused on Pacific Islanders or Native Americans. Several studies reported on >1 outcome, with 12 investigating mortality and 27 documenting Z1 complications. Complications were most frequently statistically analyzed as a single category, although 6 studies specifically addressed postsurgical infection risk. Arterial injury, need for postoperative manipulation, thromboembolic events, re-
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FIGURE 1. Flow chart depicting the literature search and selection of relevant articles within the subfields of orthopedic surgery.
operation, and the development of posttraumatic psychological disorders were evaluated in 1 study each. Fifty-two percent (n = 17) of all investigations were conducted using national datasets. In addition, only 33% (n = 11) specifically focused on the role of race or ethnicity on postsurgical complications and mortality. Of these, 5 were spine surgical studies,17–19,21,24 4 involved joint replacement,10,31,35,39 and 1 each evaluated tibia47 and hip fractures.45 None of these investigations were prospective in nature.
Prevalence of Disparities Twenty-one publications (64%) documented Z1 statistically significant health care disparities in racial/ethnic minority populations. Fifty-percent (n = 7) of all spine studies and 75% (n = 12) of all investigations involving joint replacement reported a disparity. Moreover, among works conducted using a national dataset, a disparity was reported 71% of the time (n = 12), whereas 64% (n = 7) of efforts that intended to assess the association between race/ethnicity and complications or mortality identified such a finding. Among investigations studying nonelective (eg, oncology or orthopedic trauma) procedures, 50% (4 of 8) recorded a health care disparity. Overall, only 3 studies (9%) controlled for both income-related and insurance-related factors in their statistical analyses, whereas 6 (18%) addressed income alone and 12 (36%) controlled solely for insurance. Studies that specifically addressed mortality risk identified a disparity only 50% (6 of 12 publications) of the time, although Kalanithi et al25 did record an association between African American race and complex disposition [OR, 1.54 (95% CI, r
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NIS 2002–2006 (spinal fusion)
Cahill et al26
White White
Non-white Black, Hispanic
Black Non-white (black, other)
Complications
Non-white (black, Hispanic, Asian, Pacific Islander)
White
White
White
White
White
Non-white
African American
White
Black
Complications
Complications and “complex disposition” (mortality or discharge to location other than home) Complications
White
Black
White
White
White
Non-whites at increased risk of complications following anterior cervical fusion [OR, 1.24 (95% CI, 1.04, 1.47)], thoracic fusion [OR, 1.58 (95% CI, 1.21, 2.07)], and lumbar fusion [OR, 1.35 (95% CI, 1.19, 1.54)] Black patients at increased risk of complications [OR, 1.9 (95% CI, 1.3, 2.7)] No significant difference in the rate of complications between non-white and white patients (P = 0.12)
No significant association between race and the rate of complications (P = 0.8277). African Americans more likely to have a complex disposition [OR, 1.54 (95% CI, 1.17, 2.03)]
Non-white race was not associated with an increased risk of mortality [HR, 1.1 (95% CI 0.8, 1.5)] Black patients were at an increased risk of mortality as compared with whites [OR, 1.57 (95% CI, 1.16, 2.12) P < 0.001]. Hispanics were not at increased risk of mortality [OR, 1.07 (95% CI, 0.63, 1.82) P = 0.8]
No significant association identified between black race and the rate of complications (P = 0.39) or mortality (P = 0.78) In the spine surgery cohort, no association was found between race and survival. Survival HR (for whites) 0.73, (95% CI, 0.5, 1.07)
Non-whites were at increased risk of mortality compared with whites [OR, 1.6 (95% CI, 1.1, 2.4) P = 0.02]. Black patients were also at increased risk of mortality [OR, 2.1, (95% CI, 1.25, 3.6) P = 0.005]. Neither non-whites [OR, 1.0 (95% CI, 0.8, 1.3) P = 0.9] or blacks [OR, 0.8 (95% CI, 0.6, 1.2) P = 0.3] were at increased risk of complications Black patients were at increased risk of pulmonary embolism [OR, 1.8 (95% CI, 1.3, 2.4) P < 0.0005]
African-Americans were at an increased risk of postoperative complications at 90 d after index procedure [OR, 1.611 (95% CI, 1.116, 2.326) P = 0.04] Non-whites were not at increased risk of complications as compared with whites [OR (for white patients) 0.48 (95% CI, 0.21, 1.14) P = 0.09]
Findings
No
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
No
Yes
Disparity Identified Other Finding
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(Continued )
N/A
N/A
N/A
Black patients and Hispanic patients less likely to receive anterior cervical surgery N/A
N/A
Whites more likely to receive surgery than black patients N/A
N/A
Non-White patients had shorter hospital LOS.
African Americans had longer hospital LOS and were prescribed fewer medications White patients more likely to receive surgery
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Patil et al27 NIS 1993–2002 (spinal cord tumor) Patil et al28 NIS 1993–2002 (spinal metastases)
NIS 1993–2002 (spondylolisthesis)
Kalanithi et al25
Complications (thromboembolic events) Schoenfeld Spine Patients Outcomes Mortality, complications 21 et al Research Trial (SPORT) Surveillance, Mortality Cahill Epidemiology, and et al22 End Results (SEER) database (breast cancer metastases) Partners’ Research Mortality Harris 23 Patient Data Registry et al NIS 1992–2005 (anterior Mortality Alosh cervical surgery) et al24
NIS 2002–2009
Fineberg et al20
Mortality, complications
Non-white (African American, Hispanic, Asian/Pacific Islander, Native American) Non-white, black
African American
Comparison Group*
Schoenfeld National Trauma Databank et al19
Nationwide Inpatient Complications Sample (NIS) 1998–2007 (idiopathic scoliosis)
Nuno et al18
Complications
Outcome(s) Evaluated
Medicaid data of Thomson Reuter’s MarketScan
Data Source
Lad et al17
References
Minority Population(s) Studied*
TABLE 1. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Spine Surgery
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DISCUSSION
*Reported as characterized by the authors of the study. CI indicates confidence interval; LOS, length of stay; OR, odds ratio.
White Black Complications (reoperation) Ciol et al30
1.17, 2.03)], a classification that included in-hospital death as well as discharge to a location other than home. Interestingly, only 44% (4 of 9) of efforts providing outcomes for Hispanics/Latinos and 36% (4 of 11) of works documenting results for non-white cohorts encountered a disparity. In contrast, 77% (17 of 22) of investigations reporting on African Americans/blacks were able to identify Z1 health care disparities in the risk of postoperative complications or mortality (Fig. 2). The largest effect size for mortality was encountered in the work of Schoenfeld et al,19 where black patients were found to be at >2-fold increased risk of mortality [OR, 2.1 (95% CI, 1.25, 3.6)] following spinal trauma as compared with whites. Escalante and Beardmore43 published the largest effect size for a complication, finding that Hispanic patients were at >2 times the risk of complications [RR, 2.86 (95% CI, 1.43, 5.56)] when compared with a non-Hispanic cohort undergoing total knee arthroplasty. Statistical testing indicated that there was no significant association between the type of procedure under study (P = 0.3), study focus (P = 1.0), or use of a national dataset (P = 0.4) and the identification of disparities. Investigations reporting on African American populations encountered disparities at a significantly higher rate than those examining non-white (P = 0.02) cohorts, whereas a borderline association (P = 0.08) existed when compared with studies examining Hispanic patients. The I2 for studies reporting outcomes using an effect size and 95% CI was 82.5%, indicating that substantial heterogeneity was present and pooled meta-analysis was determined to be inappropriate. The test for small study effects was not significant (P = 0.1), demonstrating a low likelihood of publication bias.
Black patients were at decreased risk of reoperation [RR, 0.56 (95% CI, 0.44, 0.72)]
N/A No White
Duke University Medical Center/ Durham Regional Hospital Medicare Claims Data (1985) Friedman et al29
Complications (infection)
Non-white
Multivariable analysis found non-white race was not associated with the risk of infection [OR, 2.5 (95% CI, 0.88, 7.1) P = 0.08]
Disparity Identified Findings Comparison Group* Data Source References
Outcome(s) Evaluated
Minority Population(s) Studied*
TABLE 1. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Spine Surgery (continued)
Other Finding
Schoenfeld et al
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Since the civil rights movement of the 1960s, the extent of health care disparities within American medicine has been reduced, yet evidence of inequality persists as demonstrated in several works addressing disparate outcomes between minorities and white patients.1–6,48 This issue has been incompletely explored within the orthopedic discipline.8,9 We performed a systematic review of the literature, identifying 33 publications since 1993 (Tables 1–3) that met inclusion criteria. Sixty-four percent of these identified Z1 health care disparities related to mortality or postoperative complications in non-white, African American, or Hispanic populations. Racial and ethnic minorities seem to be at elevated risk of complications and mortality following spine surgery or joint replacement. There was insufficient evidence—positive or negative—to support conclusions regarding other aspects of orthopedic surgery, or to generalize findings to the field in its entirety. Studies specific to African American patients were more likely to identify health care disparities compared with those specific to Hispanics or efforts that amalgamated results for individuals from different minorities into a single non-white classification. Of equal importance, we were only able to identify 11 studies (33% of the total) that focused on identifying orthopedic health care r
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r
NIS 1998–2007
Poultsides et al32
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California Office of Statewide Health Planning and Development Veterans Administration Surgical Quality Improvement Program (VASQIP, 1996–2003) California Office of Statewide Health Planning and Development VASQIP (1996–2000)
SooHoo et al36
Mortality, complications (infection) Mortality
Medicare Claims Data (1995–1996)
Mahomed et al41
Black
Black
Black, Hispanic Black, Hispanic
Complications
Medicare Claims Data (2000)
Black, Hispanic
Complications
White
White
White
White
White
African Non–African American American (99% white)
White
White
White
White
Complications (arterial injury)
Black, Hispanic, Asian
Black, Hispanic, Asian Black, Hispanic
Black, Hispanic, Asian
White
White
White
White
Comparison Group*
Black race associated with increased risk of mortality [OR, 1.48 (95% CI, 1.03, 2.11)]
Black race associated with higher rate of pulmonary embolism [OR, 1.74 (95% CI, 1.36, 2.23) P < 0.001]. Hispanic ethnicity associated with increased risk of infection [OR, 1.21 (95% CI, 1.03, 1.43) P = 0.02] THA cohort: neither black race nor Hispanic ethnicity were associated with an increased risk of complications TKA cohort: black patients had a higher risk of noninfectionrelated complications [OR, 1.5 (95% CI, 1.08, 2.1) P = 0.02] and infection-related complications [OR, 1.42 (95% CI, 1.06, 1.9) P = 0.02]. Hispanic patients were at increased risk of infection [OR, 1.64 (95% CI, 1.08, 2.49) P = 0.02] Blacks had a tendency toward higher mortality [rate ratio, 1.4 (95% CI, 1.0, 1.8)] and deep infection [rate ratio, 1.5 (95% CI, 1.0, 2.1).
Black patients had increased risk of complications compared with whites [OR, 1.19 (95% CI, 1.05, 1.35) P = 0.007]. Hispanics had lower risk of complications [OR, 0.75 (95% CI, 0.67, 0.85) P < 0.001] African Americans at increased risk of arterial injury during arthroplasty procedures [OR, 2.5 (95% CI, 1.2, 5.3) P = 0.02]
Black race associated with increased risk of complications [OR, 1.2 (95% CI, 1.07, 1.35)]. Black race associated with increased risk of mortality [OR, 1.65 (95% CI, 1.33, 2.05)]w Black race [OR, 1.39 (95% CI, 1.22, 1.58) P < 0.001] and Hispanic ethnicity [OR, 1.5 (95% CI, 1.28, 1.75) P < 0.001] associated with increased risk of infection Black race was not associated with risk of infection [OR, 1.23 (95% CI, 0.88, 1.71) P = 0.223]. Hispanic ethnicity associated with a decreased risk of infection [OR, 0.69 (95% CI, 0.49, 0.98) P = 0.038] No significant risk of infection associated with black race [OR, 0.63 (95% CI, 0.29, 1.34)] or Hispanic ethnicity [OR, 1.52 (95% CI, 0.9, 2.57)] Black patients at an increased risk of necessitating a manipulation [OR, 2.13 (95% CI, 1.46, 3.11)]. No association noted for Hispanic ethnicity [OR, 1.4 (95% CI, 0.35, 5.54)]
Black race was associated with a higher complication rate [OR, 1.678 (95% CI, 1.346, 2.092) P < 0.0001] No association between race and complications (P = 0.83) or mortality (P = 0.74)
Findings
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
Disparity Identified
Blacks had lower rates of primary and revision total knee replacement Black patients less likely to receive primary or revision THA (Continued )
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Increased 5 y revision rates for African Americans N/A
N/A
Other Findings
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Mahomed et al40
Ibrahim et al39
SooHoo et al38
Abularrage et al37
Multicenter Study (2004–2010)
Complications (infection) after THA Complications (need for postoperative manipulation) after TKA Complications
Namba et al34 Kaiser Permanente Registry (2001–2009)
Springer et al35
Complications (infection) after TKA
Black, Hispanic
Black
Mortality, complications Complications (infection)
African American
Black
Mortality, complications
Complications
Namba et al33 Kaiser Permanente Registry (2001–2009)
Adelani et al31
Pennsylvania Health Care Cost Containment Council NIS 1998–2005
NSQIP (2005–2010)
Data Source
Minority Population Studied*
Blum et al10
Pugely et
al11
References
Outcome(s) Evaluated
TABLE 2. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Total Joint Arthroplasty
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Medicare Claims Data (1983–1985)
Mortality
Non-white
Non-Hispanic (all complications occurred in nonHispanic whites) White
White
Non-white Hispanic
White
Comparison Group*
Non-white
Minority Population Studied*
Non-white race was not associated with mortality [HR, 1.01 (95% CI, 0.59, 1.73)]
TKA cohort: non-whites at increased risk of complications [OR (whites), 0.793 (95% CI, 0.666, 0.943)] Hispanic patientsz were at a significantly increased risk of wound healing complications [RR, 2.86 (95% CI, 1.43, 5.56)]
THA cohort: no impact of race on complications
Findings
No
Yes
Yes
No
Disparity Identified
N/A
Non-white patients had longer LOS
Non-white patients had longer LOS
Other Findings
r
Non-white
Lower Extremity Complications (postinjury Assessment psychological disorder) after Project severe lower limb injury
McCarthy et al46
Neuman et al45
Temple Mortality, complications Non-white University (infection) after tibia fracture (black, Hospital Hispanic, trauma dataset other) Medicare Mortality after hip fracture Black 2002–2006 (NY, IL, TX)
Piposar et al47
Outcome(s) Evaluated
Non-whites were more likely to screen positive for psychological disorder [OR, 1.55 (95% CI, 1.11, 2.16)]
Black surgical patients had a lower rate of survival as compared with whites (0.779 vs. 0.799, P < 0.001)
White
White
No increased risk of infection among minority patients [OR, 1.2 (95% CI, 0.44, 3.31) P = 1.0]. No increased rate of mortality among minority patients (P = 0.2)
White
Findings
Yes
Yes
No
Disparity Identified
Black patients more likely to receive nonoperative treatment N/A
N/A
Other Finding
Data Source
Medical Care
References
Minority Population(s) Comparison Studied Group
TABLE 3. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Other Orthopedic Procedures
*Reported as characterized by the authors of the study. w Data reported in the table reflect those documented in the text of the paper.26 Different figures, however, are presented in the article’s Table 3, specifically: OR, 1.70 (95% CI, 1.37, 2.10) for mortality and OR, 1.54 (95% CI, 1.42, 1.68) for complications.26 z In this study, the referent group was a non-Hispanic cohort and 61% (225/367) of the population underwent joint replacement, with the remainder receiving other types of orthopedic interventions. All 13 complications in nonHispanic patients, however, occurred in non-Hispanic whites. CI indicates confidence interval; LOS, length of stay; HR, hazard ratio; OR, odds ratio; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Whittle et al44
Complications
VASQIP and VA inpatient Complications medical dataset (1991–1997)
Data Source
Escalante and Rancho Los Amigos Arthritis Unit Beardmore43z
Weaver et al42
References
Outcome(s) Evaluated
TABLE 2. Findings From Studies That Evaluated the Association of Race/Ethnicity With Mortality or Complications After Total Joint Arthroplasty (continued)
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Race and Ethnicity in Orthopedics
FIGURE 2. Forest plot depicting the population size (gray box), effect size (ES), and 95% confidence intervals (CI) of non-white or African American race on mortality or complications after orthopedic surgery. Only those studies (n = 25) that reported outcomes using ES and 95% CI for non-white or African American patients are included in the Forest plot.
disparities in minority populations and 3 that performed appropriate controls for the effect of health insurance and socioeconomic status. To the best of our knowledge, only 2 prior works have conducted systematic reviews of health care inequality in orthopedics.9,12 Nwachukwu et al9 cataloged 9 studies that considered disparities in outcome following joint replacement. These authors concluded that minority patients were at increased risk of complications after total hip or knee procedures, although the strongest association between race/ ethnicity and outcome was with length of hospital stay. Schoenfeld et al12 surveyed the spine literature, including 11 articles in their systematic review. This group also performed a meta-analysis of 4 works and reported that non-white patients were at increased risk of unfavorable outcomes [risk ratio, 1.3 (95% CI, 1.2, 1.4), P = 0.003] after spine surgery.12 Neither of these efforts, however, focused their reviews on complications or mortality, nor did they deconstruct results by race or ethnicity. In the current investigation, health care disparities were identified at a significantly higher rate in studies that reported results for African Americans (77%) as opposed to those that grouped disparate racial and ethnic minorities into the heterogeneous classification of non-white (36%, P = 0.02), highlighting the importance of examining outcomes by meaningful racial or ethnic definitions. A borderline difference (P = 0.08), likely due to the limited number of publications under consideration, was also appreciated when comparing studies involving African Americans to those that assessed outcomes among Hispanics. As several scholars point out, numerous variables play a role in influencing r
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health care inequality including socioeconomic status, attitudes toward health care use, and trust of the health care system.1,3,9,12,21,48 It should be noted that none of the works included in this review sought to explain the underlying factors responsible for identified disparities. Some explanatory factors may be masked by the social and nonscientific constructs of race or ethnicity, particularly when such classifications encompass multiple heterogeneous cohorts1,12,48 or include Hispanic and Latino patients whose outcomes may be influenced to a greater extent by acculturation, or neighborhood factors, than other minority groups.49 For example, the non-white group in many studies is not necessarily representative of underserved, or medically disadvantaged, minority populations. Similarly, the designation of Hispanic/Latino is a broad category that can be applied to a diverse population representing different countries of origin, immigration status, English language facility, cultural values, and socioeconomic class.49 When grouping individuals of diverse background into a single stratum, the result may be a bias toward the population mean, thus underrepresenting disparities that may exist within certain subsets. This systematic review also identified substantial limitations in the current state of health care disparities research in orthopedics. The overwhelming majority of studies included in this review were retrospective in nature and only 33% specifically intended to investigate the influence of race or ethnicity on outcomes after orthopedic surgery. As a result, there is a large potential for many of these works to be confounded by underlying biases, or underpowered to detect differences among the minority patients in their cohort www.lww-medicalcare.com |
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(Fig. 2). Furthermore, 91% of included studies addressed spinal surgery or joint replacement and none examined the subspecialties of foot and ankle surgery, hand surgery, shoulder surgery, or sports medicine. Although we identified 11 articles investigating the role of race and ethnicity on outcomes following hip fracture, 10 had to be excluded (Appendix 2, Supplemental Digital Content 2, http://links. lww.com/MLR/A785). Thus, although this review summarizes findings within the published orthopedic literature, the results suggest that we simply do not know the current state of disparities for the discipline as a whole. Our work itself also has certain limitations, beyond those imposed by the state of the literature, including the prospect of publication bias. We maintain that the potential for publication bias to confound our results is less likely, however, given the result of our test for small study effects (P = 0.1). This investigation suggests crucial gaps in the orthopedic literature, despite the field’s importance to American health care. First, there is a paucity of data regarding the impact of minority status on orthopedic surgical outcomes for several subspecialties within the field, including sports medicine, foot and ankle surgery, upper extremity surgery, orthopedic trauma, and oncology. This review might serve as a call for qualified health services researchers to explore disparities in these arenas. Second, researchers should report findings by racial or ethnic group rather than consolidate patients into a single category of non-white, as such a practice underestimates the presence of health care inequities. Third, investigations conducting research on minority populations should also adjust for the effect of income and insurance status on study outcomes. Finally, relatively few works have been specifically designed to enable accurate determinations regarding health care inequalities in orthopedic surgery and none have shed light on the underlying reasons for observed disparities. Furthermore, at present, no prospective investigation has been conducted with the intent of evaluating the impact of race or ethnicity on adverse outcomes after orthopedic interventions. A large multicenter prospective effort could control for many of the socioeconomic, cultural, and health system–based factors that might confound retrospective observational studies. Supplemented by appropriate simulated patient and randomized vignette studies to isolate different mechanisms amenable to intervention, such work is necessary to identify the current roles that race and ethnicity play in modulating the risk of mortality and complications after orthopedic surgery. One might ask, what are the implications of these results for the practicing clinician? We would suggest, at a minimum, that our findings highlight the fact that disparities in acute postsurgical outcomes currently exist within the field of orthopedic surgery. To mitigate their potential, it is imperative that physicians administer culturally competent care to patients and be vigilant regarding practices that may have an adverse impact on outcomes for individuals from disadvantaged backgrounds. To comprehensively address this issue, it is necessary that the orthopedic practitioner not only tailor interventions to the preoperative and postoperative periods, but also in the setting of the index hospitalization itself.
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37. Abularrage CJ, Weiswasser JM, Dezee KJ, et al. Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. J Vasc Surg. 2008;47:803–807; discussion 807-808. 38. SooHoo NF, Lieberman JR, Ko CY, et al. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480–485. 39. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arth Rheumatol. 2005;52:3143–3151. 40. Mahomed NN, Barrett J, Katz JN, et al. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am. 2005;87:1222–1228. 41. Mahomed NN, Barrett JA, Katz JN, et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2003;85-A:27–32. 42. Weaver F, Hynes D, Hopkinson W, et al. Preoperative risks and outcomes of hip and knee arthroplasty in the Veterans Health Administration. J Arthroplasty. 2003;18:693–708. 43. Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol. 1995;22:1844–1851. 44. Whittle J, Steinberg EP, Anderson GF, et al. Mortality after elective total hip arthroplasty in elderly Americans. Age, gender, and indication for surgery predict survival. Clin Orthop Relat Res. 1993;295: 119–126. 45. Neuman MD, Fleisher LA, Even-Shoshan O, et al. Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities. Med Care. 2010;48:314–320. 46. McCarthy ML, MacKenzie EJ, Edwin D, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003;85-A:1689–1697. 47. Piposar J, Fowler JR, Gaughan JP, et al. Race may not affect [correct] outcomes in operatively treated tibia fractures. Clin Orthop Relat Res. 2012;470:1513–1517. 48. Kirby JB, Taliaferro G, Zuvekas SH. Explaining racial and ethnic disparities in health care. Med Care. 2006;44:I64–I72. 49. Franzini L, Ribble JC, Kiddie AM. Understanding the Hispanic paradox. Ethn Dis. 2001;11:496–518.
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