Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
J Bone Joint Surg Am. 2022 Jun 1;104(11):949-958. doi: 10.2106/JBJS.21.00465. Epub 2022 Apr 15.
There is a paucity of literature on racial differences across a full total joint arthroplasty (TJA) "episode of care" and beyond. Given various incentives, the Comprehensive Care for Joint Replacement (CJR) program in the U.S. may have impacted preexisting racial differences across this care continuum. The purposes of the present study were (1) to assess trends in racial differences in care/outcome characteristics before, during, and after TJA surgery and (2) to assess if the CJR program coincided with reductions in these racial differences.
This retrospective cohort study includes data on 1,483,221 TJAs (based on Medicare claims data, 2013 to 2018). Racial differences between Black and White patients were assessed for (1) preoperative characteristics (Deyo-Charlson comorbidity index, patient sex, and age), (2) characteristics during hospitalization (length of stay, blood transfusions, and combined complications), and (3) postoperative characteristics (90 and 180-day readmission rates and institutional post-acute care). Additionally, Medicare payments for each period were assessed. Racial differences (Black versus White patients) were expressed in terms of odds ratios (ORs) and 95% confidence intervals (CIs) per year. A "difference-in-differences" analysis (comparing before and after CJR implementation, with non-CJR hospitals being used as controls) estimated the association of the CJR program with changes in racial differences.
In both 2013 and 2018, Black patients (n = 74,390; 5.0%) were more likely than White patients to have a higher Deyo-Charlson comorbidity index (score of >0) (OR = 1.32 [95% CI = 1.28 to 1.36] and OR = 1.32 [95% CI = 1.28 to 1.37]), to require more transfusions (OR = 1.55 [95% CI = 1.49 to 1.62] and OR = 1.77 [95% CI = 1.56 to 2.01]), to be discharged to institutional post-acute care (OR = 1.40 [95% CI = 1.36 to 1.44] and OR = 1.49 [95% CI = 1.43 to 1.56]), and to be readmitted within 90 days (OR = 1.38 [95% CI = 1.32 to 1.44] and OR = 1.21 [95% CI = 1.13 to 1.29]) (p < 0.05 for all). Adjusted difference-in-differences analyses demonstrated that the CJR program coincided with reductions in racial differences in 90-day readmission (-1.24%; 95% CI, -2.46% to -0.03%) and 180-day readmission (-1.28%; 95% CI, -2.52% to -0.03%) (p = 0.044 for both).
Racial differences persist among patients managed with TJA. The CJR program coincided with reductions in some racial differences, thus identifying bundle design as a potential novel strategy to target racial disparities.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
在整个全关节置换术（TJA）“治疗过程”及之后，关于种族差异的文献相对较少。鉴于各种激励措施，美国的综合关节置换护理（CJR）计划可能已经影响了这一护理连续体中现有的种族差异。本研究的目的是：（1）评估 TJA 手术前后护理/结局特征的种族差异趋势；（2）评估 CJR 计划是否与这些种族差异的减少有关。
本回顾性队列研究纳入了 1483221 例 TJA（基于医疗保险索赔数据，2013 年至 2018 年）。评估了黑人和白人患者之间的种族差异，包括（1）术前特征（Deyo-Charlson 合并症指数、患者性别和年龄），（2）住院期间的特征（住院时间、输血和合并并发症），以及（3）术后特征（90 天和 180 天再入院率和机构康复后护理）。此外，还评估了每个时期的医疗保险支付情况。种族差异（黑人与白人患者）用优势比（OR）和 95%置信区间（CI）表示，每年一个。“差异中的差异”分析（比较 CJR 实施前后，以非 CJR 医院作为对照）估计了 CJR 计划与种族差异变化的关联。
2013 年和 2018 年，黑人患者（n=74390；5.0%）比白人患者更有可能患有更高的 Deyo-Charlson 合并症指数（评分>0）（OR=1.32[95%CI=1.28 至 1.36]和 OR=1.32[95%CI=1.28 至 1.37]），更需要输血（OR=1.55[95%CI=1.49 至 1.62]和 OR=1.77[95%CI=1.56 至 2.01]），出院到机构康复后护理（OR=1.40[95%CI=1.36 至 1.44]和 OR=1.49[95%CI=1.43 至 1.56]），90 天内再入院（OR=1.38[95%CI=1.32 至 1.44]和 OR=1.21[95%CI=1.13 至 1.29]）（所有 p<0.05）。调整后的差异中的差异分析表明，CJR 计划与 90 天再入院（-1.24%；95%CI，-2.46% 至 -0.03%）和 180 天再入院（-1.28%；95%CI，-2.52% 至 -0.03%）的种族差异减少有关（p=0.044）。
接受 TJA 治疗的患者中仍存在种族差异。CJR 计划与一些种族差异的减少有关，因此确定捆绑设计是解决种族差异的潜在新策略。
预后 III 级。请参阅作者说明，以获取完整的证据水平描述。
