Assessing social disparities in inpatient vs. outpatient arthroplasty: a in-state database analysis.

Given the growing emphasis on patient outcomes, including postoperative complications, in total joint arthroplasty (TJA), investigating the rise of outpatient arthroplasty is warranted. Concerns exist over the safety of discharging patients home on the same day due to increased readmission and complication rates. However, psychological benefits and lower costs provide an incentive for outpatient arthroplasty. The influence of social determinants of health disparities on outpatient arthroplasty remains unexplored. One metric that assesses social disparities, including the following individual components: socioeconomic status, household composition, minority status, and housing and transportation, is the Social Vulnerability Index (SVI). As such, we aimed to compare: (1) mean overall SVI and mean SVI for each component and (2) risk factors for total complications between patients undergoing inpatient and outpatient arthroplasty. Patients who underwent TJA between January 1, 2022 and December 31, 2022 were identified. Data were drawn from the Maryland State Inpatient Database (SID). A total of 7817 patients had TJA within this time period. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). The mean SVI was compared between inpatient and outpatient procedures for each themed score. The SVI identifies communities that may need support cause by external stresses on human health based on four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. The SVI uses the United States Census data to rank census tracts for each individual theme, as well as an overall social vulnerability score. The higher the SVI, the more social vulnerability, or resources needed to thrive in that area. Multivariate logistic regression analyses were performed to identify independent risk factors for total complications following TJA after controlling for risk factors and patient comorbidities. Total complications included: infection, aseptic loosening, dislocation, arthrofibrosis, mechanical complication, pain, and periprosthetic fracture. Patients who had inpatient arthroplasty had higher overall SVI scores (0.45 vs. 0.42, P < 0.001). The SVI scores were higher for patients who had inpatient arthroplasty for socioeconomic status (0.36 vs. 0.32, P < 0.001), minority status and language (0.76 vs. 0.74, P < 0.001), and housing and transportation (0.53 vs. 0.50, P < 0.001) compared to outpatient arthroplasty, respectively. There was no difference between inpatient and outpatient arthroplasty for household composition and disability (0.41 vs. 0.41, P = 0.99). When controlling for comorbidities, inpatient arthroplasty [Odds Ratio (OR) 1.91, 95% Confidence Interval (CI) 1.23-2.95, P = 0.004], hypertension (OR 2.11, 95% CI 1.23-3.62, P = 0.007), and housing and transportation (OR 2.00, 95% CI 1.17-3.42, P = 0.012) were independent risk factors for total complications. Inpatient arthroplasty was associated with increased social disparities across several components of deprivation as well as an independent risk factor total complications following TJA. To the best of our knowledge, this study is the first to examine the negative repercussions of inpatient arthroplasty through the lens of social disparities and can target specific areas for intervention.

Dubin J ，Bains S ，LaGreca M ，Gilmor RJ ，Hameed D ，Nace J ，Mont M ，Lundy DW ，Delanois RE ... -  《-》

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty.

In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA). Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area. When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively. The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

Dubin JA ，Bains SS ，Hameed D ，Monárrez R ，Moore MC ，Mont MA ，Nace J ，Delanois RE ... -  《-》

Inpatient vs outpatient arthroplasty: A in-state database analysis of 90-day complications.

An increase in the number of policy initiatives, such as alternative payment models, have prompted healthcare providers to examine health-care expenditures while seeking to improve quality of care. Performing total joint arthroplasty (TJA) in the outpatient setting is an attractive option in driving costs down and providing psychological benefits to patients. Concerns regarding the safety and effectiveness of same-day discharge protocols warrants further investigation, especially on the state level. Due to the lack of consensus, we aimed to compare: (1) risk factors for outpatient arthroplasty and (2) incidences of postoperative complications between inpatient vs outpatient arthroplasty using an in-state database. Patients who underwent total knee or hip arthroplasty between January 1, 2022 and December 31, 2022 were identified. Data was drawn from the Maryland State Inpatient Database (SID) and Maryland State Ambulatory Surgery and Services Database (SASD). A total of 7817 patients had TJA within this time. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). Demographic variables, medical comorbidities, and 90-day complication rates were compared between inpatient and outpatient procedures. Additional independent variables included: marital status, primary language, race, and median household income. A multivariate logistic regression analysis was performed to identify independent risk factors for complications following TJA after controlling for risk factors and patient comorbidities. Arthroplasty in the outpatient setting were more likely to be married (61.3% vs. 51.2%, p < 0.001), white (75.5% vs. 60.9%, <0.001), speak English as primary language (98.7% vs. 88.6%, p < 0.001), and have lower rates of diabetes (4.8% vs. 9.7%, p < 0.001), chronic obstructive pulmonary disease (16.3% vs. 21.8%, p < 0.001), and obesity (30.0% vs. 45.2%, p < 0.001) compared to arthroplasty in the inpatient setting, respectively. There were lower incidences of acute kidney injury (0.2 vs. 0.8%, p < 0.001) and infection (0.3% vs. 1.1%, p < 0.001) in the outpatient cohort compared to the inpatient cohort, respectively. Inpatient arthroplasty (Odds Ratio (OR) 1.98, 95% CI 1.30-3.02, p = 0.002) and hypertension (OR 2.12, 95% CI 1.23-3.64, p = 0.007) were independent risk factors for total complications following TJA. Arthroplasty in the outpatient setting showed fewer complications than compared to patients in the inpatient setting. Although multiple factors should guide the decision for arthroplasty, outpatient arthroplasty may be a safe option for select, healthier patients without the increased burden of increased complications.

Moore MC ，Dubin JA ，Bains SS ，Douglas S ，Hameed D ，Nace J ，Delanois RE ... -  《-》

Do Community-level Disadvantages Account for Racial Disparities in the Safety of Spine Surgery? A Large Database Study Based on Medicare Claims.

Racial health disparities across orthopaedic surgery subspecialties, including spine surgery, are well established. However, the underlying causes of these disparities, particularly relating to social determinants of health, are not fully understood. (1) Is there a racial difference in 90-day mortality, readmission, and complication rates ("safety outcomes") among Medicare beneficiaries after spine surgery? (2) To what degree does the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), a community-level marker of social determinants of health, account for racial disparities in safety outcomes? To examine racial differences in 90-day mortality, readmission, and complications after spine surgery, we retrospectively identified all 419,533 Medicare beneficiaries aged 65 or older who underwent inpatient spine surgery from 2015 to 2019; we excluded 181,588 patients with endstage renal disease or Social Security disability insurance entitlements, who were on Medicare HMO, or who had missing SVI data. Because of the nearly universal coverage of those age 65 or older, Medicare data offer a large cohort that is broadly generalizable, provides improved precision for relatively rare safety outcomes, and is free of confounding from differential insurance access across races. The Master Beneficiary Summary File includes enrollees' self-reported race based on a restrictive list of mutually exclusive options. Even though this does not fully capture the entirety of racial diversity, it is self-reported by patients. Identification of spine surgery was based on five Diagnosis Related Groups labeled "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck, except fusion." Although heterogeneous, these cohorts do not reflect inherently different biology that would lead us to expect differences in safety outcomes by race. We report specific types of complications that did and did not involve readmission. Although complications vary in severity, we report them as composite measures while being cognizant of the inherent limitations of making inferences based on aggregate measures. The SVI was chosen as the mediating variable because it aggregates important social determinants of health and has been shown to be a marker of high risk of poor public health response to external stressors. Patients were categorized into three groups based on a ranking of the four SVI themes: socioeconomic status, household composition, minority status and language, and housing and transportation. We report the "average race effects" among Black patients compared with White patients using nearest-neighbor Mahalanobis matching by age, gender, comorbidities, and spine surgery type. Mahalanobis matching provided the best balance among propensity-type matching methods. Before matching, Black patients in Medicare undergoing spine surgery were disproportionately younger with more comorbidities and were less likely to undergo cervical fusion. To estimate the contribution of the SVI on racial disparities in safety outcomes, we report the average race effect between models with and without the addition of the four SVI themes. After matching on age, gender, comorbidities, and spine surgery type, Black patients were on average more likely than White patients to be readmitted (difference of 1.5% [95% CI 0.9% to 2.1%]; p < 0.001) and have complications with (difference of 1.2% [95% CI 0.5% to 1.9%]; p = 0.002) or without readmission (difference of 3.6% [95% CI 2.9% to 4.3%]; p < 0.001). Adding the SVI to the model attenuated these differences, explaining 17% to 49% of the racial differences in safety, depending on the outcome. An observed higher rate of 90-day mortality among Black patients was explained entirely by matching using non-SVI patient demographics (difference of 0.00% [95% CI -0.3% to 0.3%]; p = 0.99). However, even after adjusting for the SVI, Black patients had more readmissions and complications. Social disadvantage explains up to nearly 50% of the disparities in safety outcomes between Black and White Medicare patients after spine surgery. This argument highlights an important contribution of socioeconomic circumstances and societal barriers to achieving equal outcomes. But even after accounting for the SVI, there remained persistently unequal safety outcomes among Black patients compared with White patients, suggesting that other unmeasured factors contribute to the disparities. This is consistent with evidence documenting Black patients' disadvantages within a system of seemingly equal access and resources. Research on racial health disparities in orthopaedics should account for the SVI to avoid suggesting that race causes any observed differences in complications among patients when other factors related to social deprivation are more likely to be determinative. Focused social policies aiming to rectify structural disadvantages faced by disadvantaged communities may lead to a meaningful reduction in racial health disparities. Level III, therapeutic study.

Engler ID ，Vasavada KD ，Vanneman ME ，Schoenfeld AJ ，Martin BI ... -  《-》

Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.

As outpatient total hip (THA) and knee arthroplasties (TKA) increase in popularity, concerns exist about the safety of discharging patients home the same day. The purpose of this study is to determine the complications associated with outpatient total joint arthroplasty (TJA) and to identify high-risk patients who should be excluded from these protocols. We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary TKA or THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between outpatient and traditional inpatient procedures. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes. Of the total 169,406 patients who underwent TJA, 1220 were outpatient (0.7%). The outpatient and inpatient groups had an overall complication rate of 8% and 16%, respectively. Patients aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications after THA and TKA (all P < .05). Surprisingly, outpatient TJA alone did not increase the risk of readmission (OR 0.652, 95% CI 0.243-1.746, P = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651, P = .789), and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567, P < .001). With the resources available in a hospital setting, outpatient TJA may be a safe option, but only in select, healthier patients. Care should be taken to extrapolate these results to an outpatient facility, where complications may be more difficult to manage.

Courtney PM ，Boniello AJ ，Berger RA 《-》