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Harrison TC, Blozis SA, Taylor J, Mukherjee N, Ortega LC, Blanco N, Garcia AA, Brown SA. Mixed-Methods Study of Disability Self-Management in Mexican Americans With Osteoarthritis. Nurs Res 2024; 73:203-215. [PMID: 38652692 PMCID: PMC11045046 DOI: 10.1097/nnr.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Health disparities in osteoarthritis (OA) outcomes exist both in the occurrence and treatment of functional limitation and disability for Mexican Americans. Although the effect of self-management of chronic illness is well established, studies demonstrate little attention to self-management of function or disability, despite the strong potential effect on both and, consequently, on patients' lives. OBJECTIVE The purpose of this study pilot was to develop and test key variable relationships for a measure of disability self-management among Mexican Americans. METHODS In this sequential, two-phased, mixed-methods, biobehavioral pilot study of Mexican American women and men with OA, a culturally tailored measure of disability self-management was created, and initial relationships among key variables were explored. RESULTS First, a qualitative study of 19 adults of Mexican American descent born in Texas (United States) or Mexico was conducted. The Mexican American Disability Self-Management Scale was created using a descriptive content analysis of interview data. The scale was tested and refined, resulting in 18 items and a descriptive frequency of therapeutic management efforts. Second, correlations between study variables were estimated: Disability and function were negatively correlated. Disability correlated positively with social support and activity effort. Disability correlated negatively with disability self-management, pain, and C-reactive protein. Function was positively correlated with age, pain, and depression. Liver enzymes (alanine transaminase) correlated positively with pain and anxiety. DISCUSSION This mixed-methods study indicates directions for further testing and interventions for disability outcomes among Mexican Americans.
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Affiliation(s)
| | | | | | - Nandini Mukherjee
- College of Public Health the University of Arkansas for Medical Sciences
| | | | - Nancy Blanco
- School of Nursing Universidad de Guanajuato
- School of Nursing The University of Texas at Austin
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2
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Testa EJ, Brodeur PG, Li LT, Berglund-Brown IS, Modest JM, Gil JA, Cruz AI, Owens BD. Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability. Arthrosc Sports Med Rehabil 2022; 4:e1497-e1504. [PMID: 36033183 PMCID: PMC9402473 DOI: 10.1016/j.asmr.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 06/04/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors. Methods Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type. Results In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker’s compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery. Conclusions Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation. Clinical Relevance Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.
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Affiliation(s)
- Edward J. Testa
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
- Address correspondence to Edward J. Testa, Department of Orthopaedic Surgery, Brown University, 2 Dudley St., Providence, RI 02903.
| | - Peter G. Brodeur
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Lambert T. Li
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Isabella S. Berglund-Brown
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Jacob M. Modest
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Joseph A. Gil
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Aristides I. Cruz
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Brett D. Owens
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
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Ottesen TD, Amick M, Kapadia A, Ziatyk EQ, Joe JR, Sequist TD, Agarwal-Harding KJ. The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States. J Bone Joint Surg Am 2022; 104:e47. [PMID: 35104253 DOI: 10.2106/jbjs.21.00512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.
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Affiliation(s)
- Taylor D Ottesen
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Michael Amick
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Yale University School of Medicine, New Haven, Connecticut
| | - Ami Kapadia
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Q Ziatyk
- Department of Family Medicine, Chinle Comprehensive Healthcare Facility, Chinle, Arizona
| | - Jennie R Joe
- Department of Family and Community Medicine, University of Arizona Health Sciences, Tucson, Arizona
- Native American Research and Training Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Thomas D Sequist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Department of Orthopaedic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Hurley VB. Are patients really getting what they want? The routine implementation of decision aids for patients with hip or knee osteoarthritis in the high value healthcare collaborative and alignment between patient treatment choice and receipt. J Eval Clin Pract 2021; 27:1207-1215. [PMID: 33829617 DOI: 10.1111/jep.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Alignment between patients' treatment choices and treatments received is acknowledged as an important outcome of shared decision-making (SDM), yet recent research suggests that patients' choices do not always align with their actual treatment trajectories. This paper explores the alignment of patient-expressed treatment choices (for surgery or medical management) after exposure to decision aids and treatments received among patients with hip or knee osteoarthritis within High Value Healthcare Collaborative (HVHC) systems as the collaborative integrated decision aids intended to support SDM into routine clinical practice. METHOD This retrospective cohort study examines data from adult (≥18 years) patients with hip or knee osteoarthritis who received decision aids as part of orthopaedic consultations within HVHC systems between 2012 and 2015. Multivariable logistic regression explored the association between patient-level characteristics with the odds of treatment choice-receipt alignment. RESULTS The majority of patients with knee osteoarthritis (68.3%) and hip osteoarthritis (71.9%) received treatments aligned with their choices following exposure to decision aids, but analyses reveal important differences in the odds of such alignment across patient characteristics. In adjusted models, African American patients with knee osteoarthritis had 50% lower odds of receiving treatment aligned with their choices compared with Caucasian patients (OR = 0.52, P < .05). Medicare- or Medicaid-insured knee patients had 49% and 59% lower odds (respectively) of receiving choice-aligned treatments relative to privately insured patients. Patients with knee (OR = 0.40, P < .01) or hip (OR = 0.75, P < .05) osteoarthritis at earlier decision-making stages had lower odds of receiving treatments congruent with their choices. CONCLUSION This work elucidates the odds of treatment choice-aligned care for patients within health care systems attempting to routinely integrate decision aids to support SDM into clinical practice and underscores the gaps in achieving this alignment among African American patients, those with public insurance and those at early decision-making stages.
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Affiliation(s)
- Vanessa B Hurley
- Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
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Bokshan SL, Li LT, Lemme NJ, Owens BD. Socioeconomic and Demographic Disparities in Early Surgical Stabilization Following Emergency Department Presentation for Shoulder Instability. Arthrosc Sports Med Rehabil 2021; 3:e471-e476. [PMID: 34027457 PMCID: PMC8129468 DOI: 10.1016/j.asmr.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose To describe which patients are the most likely to undergo surgical management within the same calendar year as their emergency department visit for anterior shoulder instability. Methods The State Emergency Department Databases and State Ambulatory Surgery and Services Databases from Florida were used. All patients presenting to the emergency department for anterior shoulder subluxation or dislocation between January 1 and September 30, 2017, were selected. Bivariate analysis was performed for associations with demographic variables. A binary logistic regression was performed with all significant factors to assess which were predictors of undergoing surgery the same calendar year. Results While controlling for all significant factors, we found that patients with recurrent dislocations were 3.14 times more likely to have surgery within the same year (P = .037). Patients younger than 40 years were also 2.04 times more likely to have surgery than those aged 40 years or older (P < .001). White patients were 2.47 times more likely to have surgery than black patients (P < .001). On bivariate analysis, there was an association between greater income quartile and higher odds of undergoing surgery within 30 days. Conclusions Following an emergency department visit for acute shoulder instability, the following variables were associated with undergoing surgical stabilization within the same calendar year: previous dislocation, age younger than 40, and white race. Patients living in the greatest income quartile of patients had a significantly greater percentage of patients having surgery within 30 days. This demonstrates that disparities and barriers to care may exist for patients with shoulder instability. Level of Evidence Level III, Retrospective Comparative Study.
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Affiliation(s)
- Steven L Bokshan
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Lambert T Li
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
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Cusano A, Venugopal V, Gronbeck C, Harrington MA, Halawi MJ. Where Do We Stand Today on Racial and Ethnic Health Inequities? Analysis of Primary Total Knee Arthroplasty from a 2011-2017 National Database. J Racial Ethn Health Disparities 2020; 8:1178-1184. [PMID: 32940894 DOI: 10.1007/s40615-020-00875-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of this study was to present contemporary national data on the state of racial and ethnic disparities pertaining to primary total knee arthroplasty (TKA) in the USA. METHODS The 2011-2017 National Surgical Quality Improvement Program was used to capture all patients who underwent primary TKA. The study outcomes were differences in demographic, comorbidity burden, perioperative factors, procedure utilization, hospital length of stay (LOS), and 30-day outcomes. The five major minority groups as defined by the National Institutes of Health were compared to non-Hispanic Whites. RESULTS In total, 262,954 patient records were analyzed, with racial identification available on 230,712 patients (87.7%). White patients accounted for 72.5% of all TKA procedures. There were higher rates of diabetes, hypertension, anemia, and prolonged surgery times among racial and ethnic minorities (p < 0.001). Baseline disparities were especially pronounced among non-Hispanic Blacks/African Americans who were also like to have higher rates of tobacco smoking and CHF (p < 0.001). After controlling for baseline differences, significant disparities in outcomes persisted, especially among Blacks/African Americans and Hispanics/Latinos who had higher odds for experiencing complications and readmissions (p < 0.001). All racial and ethnic groups, except Asians, had longer LOS (p < 0.001). Asian patients had significantly lower rates of readmissions, reoperations, and overall complications (p < 0.001). CONCLUSION Racial and ethnic disparities remain a public health challenge for patients undergoing TKA. While initiatives aimed at improving preoperative disease-burden and comorbidity profiles represent an important step, they alone are insufficient to fully account for or eliminate the disparities in TKA outcomes.
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Affiliation(s)
- Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Vivek Venugopal
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA
| | | | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 10A, Houston, TX, 77030, USA.
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Gronbeck C, Cusano A, Cardenas JM, Harrington MA, Halawi MJ. Primary Total Hip Arthroplasty in Hispanic/Latino Patients: An Updated Nationwide Analysis of Length of Stay, 30-Day Outcomes, and Risk Factors. Arthroplast Today 2020; 6:721-725. [PMID: 32923557 PMCID: PMC7475048 DOI: 10.1016/j.artd.2020.07.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background This study explored recent time trends in length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) pertaining to total hip arthroplasty in the Hispanic and Latino population. Methods A total of 4107 Hispanic and Latino patients who underwent primary total hip arthroplasty between 2011 and 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Annual trends in LOS and 30-day outcomes (readmission, reoperation, complications, and mortality) were calculated using univariate mixed-effect regression analyses. Risk factors for AEs were determined using multivariate analyses. Results Between 2011 and 2017, there was a significant reduction in LOS >2 midnights (67.6% to 29.5%, P < .001) among Hispanic patients, which was similar to that among non-Hispanic white patients and was also accompanied with improvements in comorbidity profiles and shorter operative times. Postoperatively, the annual rates of 30-day outcomes were comparable with those of white patients (P > .05). Chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use were the strongest independent predictors for AEs. Conclusions In the context of historically lower arthroplasty outcomes among the Hispanic and Latino population, current evidence suggests a receding tide, with annual trends showing significantly shorter LOS and comparable overall 30-day outcomes with whites. Patients with chronic kidney disease, the American Society of Anesthesiologists score >2, and chronic steroid use are at the highest risk for developing 30-day AEs.
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Affiliation(s)
| | - Antonio Cusano
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Justin M Cardenas
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Melvyn A Harrington
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mohamad J Halawi
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
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Total Hip Arthroplasty in Black/African American Patients: an Updated Nationwide Analysis. J Racial Ethn Health Disparities 2020; 8:698-703. [DOI: 10.1007/s40615-020-00829-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
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Hurley VB, Rodriguez HP, Kearing S, Wang Y, Leung MD, Shortell SM. The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery. Health Aff (Millwood) 2020; 39:100-107. [PMID: 31905066 PMCID: PMC7082857 DOI: 10.1377/hlthaff.2019.00100] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.
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Affiliation(s)
- Vanessa B Hurley
- Vanessa B. Hurley ( vh151@georgetown. edu ) is an assistant professor of Health Systems Administration at the Georgetown University School of Nursing and Health Studies, in Washington, D.C
| | - Hector P Rodriguez
- Hector P. Rodriguez is the Henry J. Kaiser Professor of Health Policy and Management and codirector of the Center for Healthcare Organizational and Innovation Research, both at the University of California (UC) Berkeley School of Public Health
| | - Stephen Kearing
- Stephen Kearing is a Reporting and Analytics programmer at the High Value Healthcare Collaborative, in Hanover, New Hampshire
| | - Yue Wang
- Yue Wang is a data analyst in the Center for Healthcare Organizational and Innovation Research, UC Berkeley School of Public Health
| | - Ming D Leung
- Ming D. Leung is an associate professor of organization and management at the UC Irvine Paul Merage School of Business
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor Emeritus of Health Policy and Management, a professor of organization behavior at the School of Public Health and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at UC Berkeley
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Molloy IB, Keeney BJ, Sparks MB, Paddock NG, Koenig KM, Moschetti WE, Jevsevar DS. Short term patient outcomes after total knee arthroplasty: Does the implant matter? Knee 2019; 26:687-699. [PMID: 30910627 PMCID: PMC6556140 DOI: 10.1016/j.knee.2019.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/20/2019] [Accepted: 01/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Newer implants for total knee arthroplasty (TKA) often gain market share at higher cost with little patient-reported and long-term clinical data. We compared outcomes after TKA using two different implants: DePuy PFC Sigma and Attune. METHODS Using a prospective data repository from an academic tertiary medical center, we analyzed 2116 TKAs (1603 Sigma and 513 Attune) from April 2011 through July 2016. Outcomes included length of surgery, length of stay, facility discharge, 90-day reoperation, range of motion (ROM) change, and patient-reported physical function (PCS). RESULTS There was no difference in length of surgery (Attune -2.87 min, P = 0.143). Implant type was not associated with extended LOS (>3 days) (OR 0.80, P = 0.439). There was no difference in facility discharge (OR 0.65, P = 0.103). Unadjusted 90-day reoperations were 0.3% for Sigma and 1.0% for Attune cohorts (P = 0.158). Sigma implants were associated with more ROM improvement in unadjusted analyses (+2.1 degree improvement P = 0.031). Fifty nine percent of the Sigma cohort and 49% of the Attune cohort achieved the minimal clinically important (MCID) change for PCS improvement, although there was no adjusted difference in achieving MCID (Attune OR 0.84, P = 0.435). There was no adjusted difference in absolute PCS improvement (Attune +0.12 score, P = 0.864). CONCLUSIONS Our data show no difference in physical function and most outcomes between Sigma and Attune. Attune implants had shorter absolute LOS, but there were no differences in extended LOS.
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Affiliation(s)
- Ilda B Molloy
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Benjamin J Keeney
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Berkley Medical Management Solutions, 10851 Mastin Street, Overland Park, KS 66210, USA; Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Michael B Sparks
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Nicholas G Paddock
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Karl M Koenig
- Department of Surgery & Perioperative Care, Dell Medical School, University of Texas at Austin, 1701 Trinity St., Austin, TX 78712, USA.
| | - Wayne E Moschetti
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - David S Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Kudibal MT, Kallemose T, Troelsen A, Husted H, Gromov K. Does ethnicity and education influence preoperative disability and expectations in patients undergoing total knee arthroplasty? World J Orthop 2018; 9:220-228. [PMID: 30364739 PMCID: PMC6198294 DOI: 10.5312/wjo.v9.i10.220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/22/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether minority ethnicity and the duration of education influence preoperative disability and expectations in patients undergoing total knee arthroplasty.
METHODS We prospectively included 829 patients undergoing primary unilateral total knee arthroplasty (TKA) from April 2013 to December 2014 at a single centre. Patients filled in pre-operative questionnaires with information regarding place of birth, duration of education, expectations for outcome of surgery and baseline characteristics. Patients were stratified based on ethnicity. Majority ethnicity was defined as born in the study country and minority ethnicity was defined as born in any other country. Similarly, patients were stratified based on duration of education in groups defined as < 9 years, 9-12 years and > 12 years, respectively.
RESULTS We found that 92.2% of patients were of majority ethnicity. We found that 24.5%, 44.8% and 30.8% of patients had an education of < 9 years, 9-12 years and > 12 years, respectively. The mean preoperative (pre-OP) oxford knee score (OKS) in the total population was 23.6. Patients of minority ethnicity had lower mean pre-OP OKS (18.6 vs 23.9, P < 0.001), higher pain levels (VAS 73.0 vs 58.7, P < 0.001), expected higher levels of post-OP pain (VAS 14.1 vs 6.1, P = 0.02) and of overall symptoms (VAS 16.6 vs 6.4, P = 0.006). Patients with > 12 years education had lower mean pre-OP OKS (21.5 vs 23.8 and 24.6, P < 0.001) and higher pre-OP VAS pain (65.4 vs 59.2 and 56.4, P < 0.001) compared to groups with shorter education. One year post-operative (post-OP) patients of minority ethnicity had lower mean OKS, higher pain and lower QoL. One year post-OP patients with > 12 years education reported higher pain compared to patients with shorter educations. However, the response-rate was low (44.6%), and therefore post-OP results were not considered to be significant.
CONCLUSION Minority ethnicity and the duration of education influence preoperative disability and expectation in patients undergoing TKA. This should be taken into account when patients are advised pre-operatively.
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Affiliation(s)
- Madeline Therese Kudibal
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre 2650, Denmark
| | - Thomas Kallemose
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre 2650, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre 2650, Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre 2650, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre 2650, Denmark
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Bao MH, Keeney BJ, Moschetti WE, Paddock NG, Jevsevar DS. Resident Participation is Not Associated With Worse Outcomes After TKA. Clin Orthop Relat Res 2018; 476:1375-1390. [PMID: 29480888 PMCID: PMC6437564 DOI: 10.1007/s11999.0000000000000002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/05/2017] [Accepted: 11/03/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Approximately one-half of all US surgical procedures, and one-third of orthopaedic procedures, are performed at teaching hospitals. However, the effect of resident participation and their level of training on patient care for TKA postoperative physical function, operative time, length of stay, and facility discharge are unclear. QUESTIONS/PURPOSES (1) Are resident participation, postgraduate year (PGY) training level, and number of residents associated with absolute postoperative Patient-Reported Outcomes Measurement Information System (PROMIS®-10) global physical function score (PCS), and achieving minimum clinically important difference (MCID) PCS improvement, after TKA? (2) Are resident participation, PGY, and number of residents associated with increased TKA operative time? (3) Are resident participation, PGY, and number of residents associated with increased length of stay after TKA? (4) Are resident participation, PGY, and number of residents associated with higher odds of patients being discharged to another inpatient facility, rather than to their home (facility discharge)? METHODS We performed a retrospective study using a longitudinally maintained institutional registry of TKAs that included 1626 patients at a single tertiary academic institution from April 2011 through July 2016. All patients who underwent primary, elective unilateral TKA were included with no exclusions. All patients were included in the operative time, length of stay, and facility discharge models. The PCS model required postoperative PCS score (n = 1417; 87%; mean, 46.4; SD, 8.5) and the MCID PCS model required pre- and postoperative PCS (n = 1333; 82%; 55% achieved MCID). Resident participation was defined as named residents being present in the operating room and documented in the operative notes, and resident PGY level was determined by the date of TKA and its duration since the resident entered the program and using the standard resident academic calendar (July - June). Multivariable regression was used to assess PCS scores, operative time, length of stay, and facility discharge in patients whose surgery was performed with and without intraoperative resident participation, accounting for PGY training level and number of residents. We defined the MCID PCS score improvement as 5 points on a 100-point scale. Adjusting variables included surgeon, academic year, age, sex, race-ethnicity, Charlson Comorbidity Index, preoperative PCS, and patient-reported mental function, BMI, tobacco use, alcohol use, and postoperative PCS time for the PCS models. We had postoperative PCS for 1417 (87%) surgeries. RESULTS Compared with attending-only TKAs (5% of procedures), no postgraduate year or number of residents was associated with either postoperative PCS or MCID PCS improvement (PCS: PGY-1 = -0.98, 95% CI, -6.14 to 4.17, p = 0.708; PGY-2 = -0.26, 95% CI, -2.01to 1.49, p = 0.768; PGY-3 = -0.32, 95% CI, -2.16 to 1.51, p = 0.730; PGY-4 = -0.28, 95% CI, -1.99 to 1.43, p = 0.746; PGY-5 = -0.47, 95% CI, -2.13 to 1.18, p = 0.575; two residents = 0.28, 95% CI, -1.05 to 1.62, p = 0.677) (MCID PCS: PGY-1 = odds ratio [OR], 0.30, 95% CI, 0.07-1.30, p = 0.108; PGY-2 = OR, 0.86, 95% CI, 0.46-1.62, p = 0.641; PGY-3 = OR, 0.97, 95% CI, 0.49-1.89, p = 0.921; PGY-4 = OR, 0.73, 95% CI, 0.39-1.36, p = 0.325; PGY-5 = OR, 0.71, 95% CI, 0.39-1.29, p = 0.259; two residents = OR, 1.23, 95% CI, 0.80-1.89, p = 0.337). Longer operative times were associated with all PGY levels except for PGY-5 (attending surgeon only [reference] = 85.60 minutes, SD, 14.5 minutes; PGY-1 = 100. 13 minutes, SD, 21.22 minutes, +8.44 minutes, p = 0.015; PGY-2 = 103.40 minutes, SD, 23.01 minutes, +11.63 minutes, p < 0.001; PGY-3 = 97.82 minutes, SD, 18.24 minutes, +9.68 minutes, p < 0.001; PGY-4 = 96.39 minutes, SD, 18.94 minutes, +4.19 minutes, p = 0.011; PGY-5 = 88.91 minutes, SD, 19.81 minutes, -0.29 minutes, p = 0.853) or the presence of multiple residents (+4.39 minutes, p = 0.024). There were no associations with length of stay (PGY-1 = +0.04 days, 95% CI, -0.63 to 0.71 days, p = 0.912; PGY-2 = -0.08 days, 95% CI, -0.48 to 0.33 days, p = 0.711; PGY-3 = -0.29 days, 95% CI, -0.66 to 0.09 days, p = 0.131; PGY-4 = -0.30 days, 95% CI, -0.69 to 0.08 days, p = 0.120; PGY-5 = -0.28 days, 95% CI, -0.66 to 0.10 days, p = 0.145; two residents = -0.12 days, 95% CI, -0.29 to 0.06 days, p = 0.196) or facility discharge (PGY-1 = OR, 1.03, 95% CI, 0.26-4.08, p = 0.970; PGY-2 = OR, 0.61, 95% CI, 0.31-1.20, p = 0.154; PGY-3 = OR, 0.98, 95% CI, 0.48-2.02, p = 0.964; PGY-4 = OR, 0.83, 95% CI, 0.43-1.57, p = 0.599; PGY-5 = OR, 0.7, 95% CI, 0.41-1.40, p = 0.372; two residents = OR, 0.93, 95% CI, 0.56-1.54, p = 0.766) for any PGY or number of residents. CONCLUSIONS Our findings should help assure patients, residents, physicians, insurers, and hospital administrators that resident participation, after adjusting for numerous patient and clinical factors, does not have any association with key medical and financial metrics, including postoperative PCS, MCID PCS, length of stay, and facility discharge. Future research in this field should focus on whether residents affect knee-specific patient-reported outcomes such as the Knee Injury and Osteoarthritis Score and additional orthopaedic procedures, and determine how resident medical education can be further enhanced without compromising patient care and safety.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Mike H Bao
- M. H. Bao, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA B. J. Keeney, W. E. Moschetti, N. G. Paddock, D. S. Jevsevar, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA B. J. Keeney, W. E. Moschetti, D. S. Jevsevar, Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA B. J. Keeney, Berkley Medical Management Solutions, a W.R. Berkley Company, Overland Park, KS, USA
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Keeney BJ, Koenig KM, Paddock NG, Moschetti WE, Sparks MB, Jevsevar DS. Do Aggregate Socioeconomic Status Factors Predict Outcomes for Total Knee Arthroplasty in a Rural Population? J Arthroplasty 2017; 32:3583-3590. [PMID: 28781014 PMCID: PMC5693700 DOI: 10.1016/j.arth.2017.07.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/29/2017] [Accepted: 07/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We sought to determine whether several preoperative socioeconomic status (SES) variables meaningfully improve predictive models for primary total knee arthroplasty (TKA) length of stay (LOS), facility discharge, and clinically significant Veterans RAND-12 physical component score (PCS) improvement. METHODS We prospectively collected clinical data on 2198 TKAs at a high-volume rural tertiary academic hospital from April 2011 through March 2016. SES variables included race and/or ethnicity, living alone, education, employment, and household income, along with numerous adjusting variables. We determined individual SES predictors and whether the inclusion of all SES variables contributed to each 10-fold cross-validated area under the model's area under the receiver operating characteristic (AUC). We also used 1000-fold bootstrapping methods to determine whether the SES and non-SES models were statistically different from each other. RESULTS At least 1 SES predicted each outcome. Ethnic minority patients and those with incomes <$35,000 predicted longer LOS. Ethnic minority patients, the unemployed, and those living alone predicted facility discharge. Unemployed patients were less likely to achieve PCS improvement. Without the 5 SES variables, the AUC values of the LOS, discharge, and PCS models were 0.74 (95% confidence interval [CI] 0.72-0.77, "acceptable"); 0.86 (CI 0.84-0.87, "excellent"); and 0.80 (CI 0.78-0.82, "excellent"), respectively. Including the 5 SES variables, the 10-fold cross-validated and bootstrapped AUC values were 0.76 (CI 0.74-0.79); 0.87 (CI 0.85-0.88); and 0.81 (0.79-0.83), respectively. CONCLUSION We developed validated predictive models for outcomes after TKA. Although inclusion of multiple SES variables provided statistical predictive value in our models, the amount of improvement may not be clinically meaningful.
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Affiliation(s)
- Benjamin J. Keeney
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA,Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New
Hampshire, 03756-0001, USA,Corresponding author: , Dartmouth-Hitchcock Medical Center,
1 Medical Center Drive, Hinman Box 7541, Lebanon, New Hampshire 03756-0001, Phone: 603-653-6037 Fax: 603-653-3554
| | - Karl M. Koenig
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA,Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New
Hampshire, 03756-0001, USA,Department of Surgery & Perioperative Care, Dell Medical School, University of Texas at Austin, 1912 Speedway,
Austin, Texas, 78712, USA
| | - Nicholas G. Paddock
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA
| | - Wayne E. Moschetti
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA,Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New
Hampshire, 03756-0001, USA
| | - Michael B. Sparks
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA,Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New
Hampshire, 03756-0001, USA
| | - David S. Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire,
03756-0001, USA,Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New
Hampshire, 03756-0001, USA
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Schairer WW, Nwachukwu BU, Warren RF, Dines DM, Gulotta LV. Operative Fixation for Clavicle Fractures-Socioeconomic Differences Persist Despite Overall Population Increases in Utilization. J Orthop Trauma 2017; 31:e167-e172. [PMID: 28538455 DOI: 10.1097/bot.0000000000000820] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Clavicle fractures were traditionally treated conservatively, but recent evidence has shown improved outcomes with surgical management. The purpose of this study was to evaluate the recent trends in operative treatment of clavicle fractures, and to analyze for patient related factors that may affect treatment strategy. METHODS The Healthcare Cost and Utilization Project (HCUP) California and Florida inpatient, outpatient, and the Emergency Department databases were used to identify all patients with clavicle fractures between 2005 and 2010. We evaluated the overall number of procedures over the study period and calculated the rates of operative and nonoperative treatment by tracking a large cohort of emergency department patients with clavicle fractures. Poisson and multivariable regression were used to identify trends and patient factors associated with treatment. RESULTS There was a 290% increase in the annual number clavicle fracture procedures over the study period. The rate of fixation increased from 3.7% to 11.1% (P < 0.001). Significant increases were seen in all patient age groups less than 65 years. Comparatively, higher rates of fixation were found in patients who were white, privately insured, and of high-income status. Lower income status was also associated with delayed surgery. CONCLUSIONS The rates of clavicle fracture fixation have increased. However, there are differences associated with socioeconomic factors including race, insurance type, and income level. In part, this likely representing both underutilization and overutilization but may also show differential access to care. This differential utilization suggests both that further work is needed to more clearly define indications for operative versus nonoperative management and to further evaluate referral systems and access to care to ensure equal and quality treatment is available for all patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William W Schairer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
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