Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA.
Florida Atlantic University College of Medicine, Boca Raton, FL, USA.
Clin Orthop Relat Res. 2023 Feb 1;481(2):202-210. doi: 10.1097/CORR.0000000000002185. Epub 2022 Apr 21.
Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk.
QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization?
Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included.
When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization.
We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions.
Level III, therapeutic study.
种族和社会经济差异与 THA 和 TKA 后的并发症和较差的患者报告结果相关，但关于根据患者居住社区的社会经济差异，了解急性后期护理资源利用的变化情况却知之甚少。髋关节和膝关节置换术是最常见的择期矫形手术之一。因此，了解社会因素可以深入了解有再入院风险的患者以及这些患者使用其他术后资源的方式。这些知识可以帮助外科医生更好地了解哪些患者有并发症或可预防再入院的风险，以及如何预测何时需要额外的监测或干预以降低这种风险。
问题/目的：(1)接受 THA 和 TKA 的患者来自社会经济压力较大的社区，其再入院率是否更高？(2)来自压力社区的患者是否有更多的术后资源利用？
记录了 2016 年至 2019 年期间在两家高容量医院接受 TKA 或 THA 的每位患者的人口统计学信息、居住的邮政编码和 Charlson 合并症指数（CCI）。患者根据其居住的邮政编码的 Distressed Communities Index（DCI）评分进行分类。DCI 结合了七个社会经济福祉指标（高中毕业率、贫困率、失业率、房屋空置率、家庭收入、就业变化和机构变化），以创建一个单一的分数。然后根据全国五分位数（繁荣、舒适、中产阶级、风险和困境）将邮政编码分为五类。选择 DCI 是因为它提供了多种重要社会经济因素的单一综合衡量标准。多变量分析采用逻辑回归、负二项回归或泊松回归，在控制年龄、性别、BMI 和合并症的情况下，研究 DCI 类别与术后资源利用的相关性。主要结局是 90 天内再入院。次要结局包括骨科团队开出的术后药物处方、患者致电外科医生办公室、参加的物理治疗课程、随访就诊和急诊就诊。共纳入 5077 例接受 TKA（平均年龄 66 ± 9 岁，59%[5077 例中的 2983 例]为女性，69%[5077 例中的 3519 例]为白人）和 5299 例接受 THA（平均年龄 63 ± 11 岁，50%[5299 例中的 2654 例]为女性，74%[5299 例中的 3903 例]为白人）。
在调整年龄、性别、种族和 CCI 后，与繁荣社区相比，压力社区 TKA 患者的再入院风险更高（比值比 1.6[95%置信区间 1.1 至 2.3]；p = 0.02），但 THA 患者则不然。在 TKA 后的次要结局中，与繁荣社区相比，高危社区的术后处方更多，但未发现其他差异。在 THA 后，根据 DCI 类别，在利用术后资源的可能性方面，没有发现明显差异。种族与再入院或资源利用无关。
我们发现社会经济压力与 TKA 后的再入院相关，但在控制相关混杂变量后，种族没有关联。这些社区的患者在 TKA 出院后并没有表现出更多或更少地使用其他资源。提高对这些差异的认识可以加强监测，并改善患者教育和沟通，以减少并发症和可预防再入院的发生频率。
三级，治疗性研究。
