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Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population

Okike, Kanu MD, MPH1; Chan, Priscilla H. MS2; Prentice, Heather A. PhD2; Navarro, Ronald A. MD3; Hinman, Adrian D. MD4; Paxton, Elizabeth W. MA2

doi: 10.2106/JBJS.18.01316
Scientific Articles
Supplementary Content

Background: Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system.

Methods: A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders.

Results: Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients.

Conclusions: In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits.

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaii

2Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California

3Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California

4Northern California Permanente Medical Group, Kaiser Permanente, San Leandro, California

E-mail address for K. Okike:

Investigation performed at the Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu, Hawaii; Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California; Southern California Permanente Medical Group, Kaiser Permanente, Harbor City, California; and Northern California Permanente Medical Group, Kaiser Permanente, San Leandro, California

A commentary by David A. Ansell, MD, MPH, and Joshua J. Jacobs, MD, is linked to the online version of this article at

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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