Advertisement

The Impact of Race and Socioeconomic Status on Total Joint Arthroplasty Care

Published:March 04, 2021DOI:https://doi.org/10.1016/j.arth.2021.03.002

      Abstract

      Background

      Racial minorities and patients from lower socioeconomic backgrounds are less likely to undergo total joint arthroplasty (TJA) for degenerative joint disease (DJD). However, when these patients do present for care, little is known about the overall severity of DJD and surgical wait times.

      Methods

      A retrospective cohort of 407 patients (131 black and 276 white) who presented to an arthroplasty clinic and went on to receive TJA was established. Severity of osteoarthritis was assessed radiographically via Kellgren-Lawrence (KL) grade. Preoperative Knee Society Score (KSS) and Harris Hip Score (HHS) were used to measure joint pain and function. Multivariate regression modeling and analysis of covariance were used to examine racial and socioeconomic differences in KL grade, KSS, HHS, and time to surgery.

      Results

      Black patients presented with significantly greater KL scores than white patients (P = .046, odds ratio = 1.65, 95% confidence interval [1.01, 2.70]). In contrast, there were no statistically significant racial differences in the mean preoperative KSS (P = .61) or HHS (P = .69). Black patients were also found to wait, on average, 35% longer for TJA (P = .03, hazard ratio = 1.35, 95% confidence interval [1.04, 1.75]). Low income was associated with higher KL grade (P = .002), lower KSS (P = .07), and lower HHS (P = .001).

      Conclusion

      Despite presenting with more advanced osteoarthritis, black patients reported similar levels of joint dysfunction and had longer surgical wait times when compared with white patients. Lower socioeconomic status was similarly associated with more severe DJD.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mather M.
        • Jacobsen L.A.
        • Pollard K.M.
        Aging in the United States.
        Popul Bull. 2015; 70: 1
        • Amen T.B.
        • Varady N.H.
        • Rajaee S.
        • Chen A.F.
        Persistent racial disparities in utilization rates and perioperative metrics in total joint arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 2015.
        J Bone Joint Surg Am. 2020; 102: 811
        • Schoenfeld A.J.
        • Tipirneni R.
        • Nelson J.H.
        • Carpenter J.E.
        • Iwashyna T.J.
        The influence of race and ethnicity on complications and mortality after orthopedic surgery: a systematic review of the literature.
        Med Care. 2014; 52: 842
        • Zhang W.
        • Lyman S.
        • Boutin-Foster C.
        • Parks M.L.
        • Pan T.J.
        • Lan A.
        • et al.
        Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty.
        J Bone Joint Surg Am. 2016; 98: 1243
        • Hinman A.D.
        • Chan P.H.
        • Prentice H.A.
        • Paxton E.W.
        • Okike K.M.
        • Navarro R.A.
        The association of race/ethnicity and total knee arthroplasty outcomes in a universally insured population.
        J Arthroplasty. 2020;
        • Stone A.H.
        • MacDonald J.H.
        • Joshi M.S.
        • King P.J.
        Differences in perioperative outcomes and complications between African American and white patients after total joint arthroplasty.
        J Arthroplasty. 2019; 34: 656
        • Allen K.D.
        • Golightly Y.M.
        • Callahan L.F.
        • Helmick C.G.
        • Ibrahim S.A.
        • Kwoh C.K.
        • et al.
        Race and sex differences in willingness to undergo total joint replacement: the Johnston County Osteoarthritis Project.
        Arthritis Care Res (Hoboken). 2014; 66: 1193
        • Figaro M.K.
        • Williams-Russo P.
        • Allegrante J.P.
        Expectation and outlook: the impact of patient preference on arthritis care among African Americans.
        J Ambul Care Manage. 2005; 28: 41
        • Groeneveld P.W.
        • Kwoh C.K.
        • Mor M.K.
        • Appelt C.J.
        • Geng M.
        • Gutierrez J.C.
        • et al.
        Racial differences in expectations of joint replacement surgery outcomes.
        Arthritis Rheum. 2008; 59: 730
        • Hanchate A.D.
        • Zhang Y.
        • Felson D.T.
        • Ash A.S.
        Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets.
        Med Care. 2008; 46: 481
        • Hausmann L.R.
        • Mor M.
        • Hanusa B.H.
        • Zickmund S.
        • Cohen P.Z.
        • Grant R.
        • et al.
        The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting.
        J Gen Intern Med. 2010; 25: 982
        • Goodman S.M.
        • Mehta B.
        • Zhang M.
        • Szymonifka J.
        • Nguyen J.T.
        • Lee L.
        • et al.
        Disparities in total hip arthroplasty outcomes: census tract data show interactions between race and community deprivation.
        J Am Acad Orthop Surg. 2018; 26: e457
        • Dowsey M.M.
        • Nikpour M.
        • Dieppe P.
        • Choong P.F.M.
        Associations between pre-operative radiographic changes and outcomes after total knee joint replacement for osteoarthritis.
        Osteoarthritis Cartilage. 2012; 20: 1095
        • Toguchi K.
        • Nakajima A.
        • Akatsu Y.
        • Sonobe M.
        • Yamada M.
        • Takahashi H.
        • et al.
        Predicting clinical outcomes after total knee arthroplasty from preoperative radiographic factors of the knee osteoarthritis.
        BMC Musculoskelet Disord. 2020; 21: 9
        • Kellgren J.H.
        • Lawrence J.S.
        Radiological assessment of osteo-arthrosis.
        Ann Rheum Dis. 1957; 16: 494
        • Kohn M.D.
        • Sassoon A.A.
        • Fernando N.D.
        Classifications in brief: Kellgren-Lawrence classification of osteoarthritis.
        Clin Orthop Relat Res. 2016; 474: 1886
        • Insall J.N.
        • Dorr L.D.
        • Scott R.D.
        • Scott W.N.
        Rationale of the Knee Society clinical rating system.
        Clin Orthop Relat Res. 1989; : 13
        • Harris W.H.
        Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation.
        J Bone Joint Surg Am. 1969; 51: 737
        • Lingard E.A.
        • Katz J.N.
        • Wright R.J.
        • Wright E.A.
        • Sledge C.B.
        Validity and responsiveness of the knee society clinical rating system in comparison with the SF-36 and WOMAC.
        J Bone Joint Surg Am. 2001; 83: 1856
        • Soderman P.
        • Malchau H.
        Is the Harris hip score system useful to study the outcome of total hip replacement?.
        Clin Orthop Relat Res. 2001; : 189
        • Neogi T.
        • Felson D.
        • Niu J.
        • Nevitt M.
        • Lewis C.E.
        • Aliabadi P.
        • et al.
        Association between radiographic features of knee osteoarthritis and pain: results from two cohort studies.
        BMJ. 2009; 339: b2844
        • Loza E.
        • Lopez-Gomez J.M.
        • Abasolo L.
        • Maese J.
        • Carmona L.
        • Batlle-Gualda E.
        • et al.
        Economic burden of knee and hip osteoarthritis in Spain.
        Arthritis Care Res. 2009; 61: 158
        • Lohmander L.S.
        • Gerhardsson de Verdier M.
        • Rollof J.
        • Nilsson P.M.
        • Engström G.
        Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: a population-based prospective cohort study.
        Ann Rheum Dis. 2009; 68: 490
        • Cleveland R.J.
        • Luong M.-L.N.
        • Knight J.B.
        • Schoster B.
        • Renner J.B.
        • Jordan J.M.
        • et al.
        Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis.
        BMC Musculoskelet Disord. 2013; 14: 297
        • Courtney P.M.
        • Huddleston J.I.
        • Iorio R.
        • Markel D.C.
        Socioeconomic risk adjustment models for reimbursement are necessary in primary total joint arthroplasty.
        J Arthroplasty. 2017; 32: 1
        • Kamath A.F.
        • Courtney P.M.
        • Bozic K.J.
        • Mehta S.
        • Parsley B.S.
        • Froimson M.I.
        Bundled payment in total joint care: survey of AAHKS membership attitudes and experience with alternative payment models.
        J Arthroplasty. 2015; 30: 2045
        • Assari S.
        • Bazargan M.
        • Chalian M.
        The Unequal Effect of Income on Risk of Overweight/Obesity of Whites and Blacks with Knee Osteoarthritis: the Osteoarthritis Initiative.
        J Racial Ethn Health Disparities. 2020; 7: 776
        • Mossey J.M.
        Defining racial and ethnic disparities in pain management.
        Clin Orthop Relat Res. 2011; 469: 1859
        • Kallai I.
        • Barke A.
        • Voss U.
        The effects of experimenter characteristics on pain reports in women and men.
        Pain. 2004; 112: 142
        • Nguyen M.
        • Ugarte C.
        • Fuller I.
        • Haas G.
        • Portenoy R.K.
        Access to care for chronic pain: racial and ethnic differences.
        J Pain. 2005; 6: 301
        • Green C.R.
        • Anderson K.O.
        • Baker T.A.
        • Campbell L.C.
        • Decker S.
        • Fillingim R.B.
        • et al.
        The unequal burden of pain: confronting racial and ethnic disparities in pain.
        Pain Med. 2003; 4: 277
        • Ibrahim S.A.
        • Siminoff L.A.
        • Burant C.J.
        • Kwoh C.K.
        Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African American and white patients.
        Arthritis Care Res. 2001; 45: 340
        • Lavernia C.J.
        • Alcerro J.C.
        • Rossi M.D.
        Fear in arthroplasty surgery: the role of race.
        Clin Orthop Relat Res. 2010; 468: 547
        • Adelani M.A.
        • Harrington M.A.
        • Montgomery C.O.
        The distribution of underrepresented minorities in U.S. Orthopaedic surgery residency programs.
        J Bone Joint Surg Am. 2019; 101: e96
        • Ramirez R.N.
        • Franklin C.C.
        Racial diversity in orthopedic surgery.
        Orthop Clin North Am. 2019; 50: 337