EXECUTIVE SUMMARY

Healthcare disparities, primarily affecting African American and Hispanic patients, persist despite years of research.

  • One study revealed African American children are three times more likely to die within 30 days after surgery.
  • Other research indicates pain scores after knee arthroplasty were higher for African American patients than for white patients.
  • Black patients are much less likely than white patients to undergo attempts at limb salvage before an amputation.

African Americans continue experiencing worse surgical outcomes than white patients. Hispanic Americans also do worse. Why do these disparities persist despite technological advances and insurance expansion?

“We don’t know what’s really going on,” says Olubukola O. Nafiu, MD, FRCA, MS, vice chair for academic affairs in the department of anesthesiology and pain medicine at Nationwide Children’s Hospital in Columbus, OH. “Some of the reasons put forward include hospital factors, systemic factors, societal factors, and ... patient factors.”

Patient factors include preoperative morbidity burden. “African American patients tend to have higher disease burdens at the time of surgery and at the time of presenting in the hospital,” Nafiu explains. “That is one explanation for why there are differences in outcomes.”

Nafiu is lead author of a recent study that showed that even among apparently healthy children, African American patients were at a higher risk of postoperative complications and mortality.1 The authors found African American children were more than three times more likely to die within 30 days after surgery.

Another study revealed pain scores after knee arthroplasty were higher for African American patients than for white patients.2

“We knew, going into this study, that African Americans underutilize knee replacement for many good reasons, including a lack of trust in the healthcare system,” says Daniel L. Riddle, PT, PhD, FAPTA, professor in the departments of physical therapy, orthopedic surgery, and rheumatology at Virginia Commonwealth University in Richmond. “Patients who are African American tend to rely on social networks to inform them about what kinds of effects these treatments have. The literature has suggested that patients who are African Americans don’t do as well, but all of these factors combine to lead to substantial underutilization of knee replacement surgery.”

Knee replacement surgery is an effective procedure for patients with severe knee osteoarthritis and knee pain. Any lack of access to the procedure can negatively affect a person’s quality of life.

For two decades, research has documented racial or ethnic differences in knee and hip joint replacement. A report from 2010 indicated African American and Hispanic individuals reported receiving joint replacement two-thirds less often than white individuals.3

The authors of a more recent study found racial and ethnic disparities continue to be a public health challenge for patients undergoing total knee arthroplasty, based on a review of data gathered from 2011 to 2017.4 “Although health disparities are well-established, limited recent data exist in orthopedic surgery, and most reports we limited by focusing on select demographic groups,” says Mohamad J. Halawi, MD, associate professor and chief quality officer for musculoskeletal services at Baylor College of Medicine.

In recent years, there have been tremendous improvements in the perioperative care of patients undergoing orthopedic surgery. Halawi decided to present an updated analysis of the state of health disparities, especially as they related to hip and knee replacement, which are among the most commonly performed orthopedic procedures. “We used a large patient sample from very recent years, and analyzed and looked at all major racial and ethnic groups in this country as defined by the National Institutes of Health,” Halawi says.

Halawi and colleagues reaffirmed what other had before them: Disparities still exist, with Black and Hispanic patients affected most. “The study also showed that the Asian group outperformed any other group as far as better outcomes,” Halawi adds.

Racial and ethnic disparities also exist in terms of access to life-enhancing surgeries. “There are a couple of surgical procedures that are life changers,” says Stephen B. Thomas, PhD, director of the Maryland Center for Health Equity at the University of Maryland. “One is cataracts, a procedure so straightforward now [that] you get a new lease on life. The second ones are knee replacement and hip replacement — they change your life by keeping you independent.”

Thomas notes another disparity exists in amputation rates. “Why are Black people with type 2 diabetes more likely to have their toes, legs, fingers amputated?” he asks.

Earlier studies show that Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. Black patients also are much less likely than white patients to undergo attempts at limb salvage before amputation.5

“These disparities would be easy to ignore if they were not so well documented,” Thomas says. “There are a lot of judgment calls made when you’re deciding whether or not to do a surgical procedure that amputates a leg vs. trying to save it.”

Although surgeons could argue they do not see these patients until their infections are severe enough that amputation is the only life-saving alternative, Thomas suggests surgeons can and should do more to stop the disparity. For instance, they could become advocates for governmental and payer policy changes that would help reduce disparities and improve everyone’s health.

“They have to use their voice, privilege, and rank ... to move the needle and look at how it’s not just what happened to the person in the surgical suite, but what happened before the surgical suite,” Thomas says. “Do I expect surgeons to end poverty or racial discrimination? No, but there’s a lot more they can do to use their voices of power.”

One important way surgery leaders can contribute to changes that improve health equity is by hiring surgeons and other staff from underrepresented minorities. The OR suite in America is relatively homogenous, says Lesly Dossett, MD, MPH, assistant professor of surgery at the University of Michigan. “We instituted a new recruitment practice, and incorporate best practices from industry to make sure to build diversity,” she reports.

Diversity includes cognitive diversity, bringing new ideas to the OR, as well as demographic diversity, Dossett adds. “A few principles we have instituted, which seem really straightforward, include open-posting every position,” she explains. “We advertise all physician positions in national organizations.”

Employing more minority surgeons and other staff could help build trust with Black and Hispanic patients. Trust is a major impediment to some minority groups accessing surgery like joint replacement. “There is a distrust that the surgery will be helpful for the patient,” Riddle says.

Surgery leaders can address this distrust through data, too. For instance, they could use data to create a decision aid that informs patients where they are in the disease spectrum, how severe their pain is when compared with other people’s pain, and how their pain would change after surgery.

“Patients who are African American should be more confident than they are that they will benefit substantially from the surgery,” Riddle says. “Showing different outcomes and showing improvement in what they could experience, compared with other people who get knee replacements, would be informative for patients who are considering knee replacement.”

REFERENCES

  1. Nafiu OO, Mpody C, Kim SS, et al. Race, postoperative complications and death in apparently healthy children. Pediatrics 2020;146:e20194113.
  2. Riddle DL, Slover J, Keefe FJ, et al. Racial differences in pain and function following knee arthroplasty: A secondary analysis from a multicenter randomized clinical trial. Arthritis Care Res (Hoboken) 2020; Mar 7:10.1002/acr.24177. doi: 10.1002/acr.24177. [Online ahead of print].
  3. Ibrahim SA. Racial variations in the utilization of knee and hip joint replacement: An introduction and review of the most recent literature. Curr Orthop Pract 2010;21:126-131.
  4. Cusano A, Venugopal V, Gronbeck C, et al. 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; Sep 17. doi: 10.1007/s40615-020-00875-8. [Online ahead of print].
  5. Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg 2011;54:420-426.