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CLINICAL RESEARCH

CORR Insights®: Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database

Bernstein, David N. MD, MBA, MA1

Author Information
Clinical Orthopaedics and Related Research: January 2022 - Volume 480 - Issue 1 - p 64-66
doi: 10.1097/CORR.0000000000001978

Where Are We Now?

Healthcare disparities, including differences in access to care, timely management of musculoskeletal pathology, and clinical outcomes, have been well documented across many orthopaedic surgery subspecialties [1-5, 7]. But there is a dearth of studies on this important topic within orthopaedic oncology [6]. Typically, attributing biological complications with social factors is inappropriate [11]. However, in orthopaedic oncology, delay in care differs from nearly all patient scenarios in other subspecialties because it could be mean the difference between life and death. Thus, we must recognize social factors that delay care in this vulnerable population in order to address them.

In the current study, Raad and colleagues [14] used the American College of Surgeons’ National Surgical Quality Improvement Program (ACS NSQIP) database from 2012 to 2018 to examine differences by race (Black versus non-Hispanic white) in timing between hospital admission and operative fixation of pathologic fractures and determine risk factors for postoperative complications by race. The authors found that Black patients not only had a longer mean wait time from admission to surgical intervention, but they also had greater odds of having a postoperative adverse event, including being readmitted to the hospital [14].

While disheartening, the unfortunate reality is that the findings in this recent scholarly work led by Dr. Carol D. Morris are not surprising. Across healthcare, disparities based on a wide range of patient characteristics, including race, gender, and other sociodemographic factors, have been well documented to varying degrees over many years. Efforts have been made to address this major injustice, but with only limited success. However, evidence of disparities and racism (including racially-motivated hate crimes) brought to light by the COVID-19 global pandemic [12] has renewed our sense of urgency for finding tangible solutions.

Where Do We Need To Go?

The recent study by Raad et al. [14] provides a window into the level of disparities within orthopaedic oncology. Action is needed to develop and implement long-lasting solutions, as the time for only conversation has passed [13]. Orthopaedic surgeons are on the front lines of delivering musculoskeletal care to patients of all backgrounds. While policymakers can play a role in helping to solve some of the challenges related to health disparities, physicians, patients, and their local communities in conjunction with health systems, hospitals, and clinics are central to any successful and lasting efforts.

It is essential we solve this crisis of injustice and ensure that the biases and inequality faced by many when receiving musculoskeletal care, including orthopaedic oncologic care, are addressed fully. We must move beyond research and implement initiatives that address the well-known health disparities in orthopaedics, including frequent transparent internal patient data review to assess for variation in care delivery by race or other social factors. By doing so, more timely corrections can be made to address such issues. Indeed, we should always evaluate and adjust any programs that we develop, understanding that it will take time and likely multiple iterations to find the true “best” solution. Efforts in this area—such as timely patient data monitoring so that biases and inequities can be addressed more efficiently, leading to less patients negatively impacted—should be championed and valued as a central part of any promotion pathway within academic medicine and/or salary or bonus structure within any setting, private, academic, or otherwise.

How Do We Get There?

Years of scholarly inquiry have demonstrated that there are serious and persistent racial and socioeconomic disparities that appear to stretch across orthopaedic surgery. The authors of these crucial scientific works should be commended for bringing attention to this important topic. However, the time for benchmarking is behind us, and we must now take our resources (time, effort, and money) and shift them toward action involving real-world, practical solutions to reduce disparities.

Different stakeholders have different levers to pull to move the needle on the development and implementation of much needed initiatives. For example, federal or state governments, through Medicare and Medicaid, respectively, can provide small financial bonuses or penalties based on meeting certain milestones consistently across race and other sociodemographic variables, such as time from arrival to the emergency department to initial imaging, admission, and surgery (if indicated). From a local perspective, it is vital that orthopaedic surgery leaders allow those dedicated to this area of work to utilize departmental resources (for example, personnel and financial) to begin implementing care pathways, trainings, and programs, as well as financially and professionally benefit from this crucial work. This can be done through re-routing certain funds that are already part of research and incentive schemes away from rewarding general scholarly activity and surgical volume to reducing disparities through the development and evaluation of programs aimed to reduce inequity. Success may be able to be measured through the comparison of the outcomes noted above (that is, time to accomplish certain care steps), as well as clinical outcomes, such as readmission, complication, or patient-reported outcome measures, across all races and sociodemographic variables.

While it is more important now than ever before to take action, this does not mean that scholarly work in this area should cease. In fact, as programs are implemented, it is imperative that they are frequently evaluated scientifically so that adjustments can happen in as close to real-time as possible to further decrease disparities efficiently. Part of this approach can be the implementation and assessment of rapid-cycle, randomized quality improvement projects, which can help ensure limited departmental resources are not wasted unnecessarily and the “best” initiatives only remain [8]. When conducting such scientific evaluation, organizations like the J. Robert Gladden Orthopaedic Society, which has a mission to “increase diversity within the orthopaedic profession and promote the highest quality musculoskeletal care for all people” [9], offer grants for medical students to attending orthopaedic surgeons [10] to support such activity. Thus, those dedicated to this work should be encouraged to seek out such opportunities. Ultimately, however, this mission of a more just health system that provides the same “chance” of receiving high-quality, timely care should be the goal of all who took the Hippocratic Oath when becoming a physician.

References

1. Ali I, Vattigunta S, Jang JM, et al. Racial disparities are present in the timing of radiographic assessment and surgical treatment of hip fractures. Clin Orthop Relat Res. 2020;478:455-461.
2. Amen TB, Varady NH, Rajaee S, Chen AF. Persistent racial disparities in utilization rates and perioperative metrics in total joint arthroplasty in the US: a comprehensive analysis of trends from 2006 to 2015. J Bone Joint Surg Am. 2020;102:811-820.
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4. Bernstein DN, Merchan N, Fear K, Rubery PT, Mesfin A. Greater socioeconomic disadvantage is associated with worse symptom severity at initial presentation in patients seeking care for lumbar disc herniation. Spine (Phila Pa 1976). 2021;46:464-471.
5. Dy CJ, Lane JM, Pan TJ, Parks ML, Lyman S. Racial and socioeconomic disparities in hip fracture care. J Bone Joint Surg Am. 2016;98:858-865.
6. Gebhardt MC. Perspectives on health disparities in orthopaedic oncology. J Am Acad Orthop Surg. 2007;15(suppl 1):S5-7.
7. Harris A, Guadix SW, Riley LH 3rd, et al. Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the affordable care act, 2006-2014. Spine J. 2021;21:64-70.
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9. J. Robert Gladden Orthopaedic Society (JRGOS). Mission. Available at: https://www.gladdensociety.org/mission. Accessed August 8, 2021.
10. J. Robert Gladden Orthopaedic Society. Research grants. Available at: https://www.gladdensociety.org/research-grants. Accessed August 8, 2021.
11. Leopold SS. Editorial: Beware of studies claiming that social factors are "independently associated" with biological complications of surgery. Clin Orthop Relat Res. 2019;477:1967-1969.
12. Ndugga N, Artiga S. Disparities in health and health care: 5 key questions and answers. Kaiser Family Foundation. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/. Accessed August 7, 2021.
13. Owusu-Akyaw K. The forward movement: Amplifying black voices on race and orthopaedics-no room for bystanders. Clin Orthop Relat Res. 2021;479:1433-1434.
14. Raad M, Puvanesarajah V, Wang KY, et al. Do disparities in wait times to operative fixation for pathologic fractures of the long bones and 30-day complications exist between black and white patients? A study using the NSQIP database. Clin Orthop Relat Res. 2022;480:57-63.
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