Racial differences in type of surgical procedure performed for proximal humerus fractures

  • Nitin B. Jain
  • Laurence D. Higgins
  • Elena Losina
  • Ricardo Pietrobon
  • Jeffrey N. Katz
Original Article

Abstract

Background

Proximal humeral fracture constitutes a medical emergency on most occasions in which the decision to perform either open reduction and internal fixation (ORIF) or hemiarthroplasty is determined by the operating surgeon. Hemiarthroplasty is a more expensive and technically challenging procedure that requires compliance with rigorous and prolonged rehabilitation postsurgically. We assessed whether racial differences exist in utilization of hemiarthroplasty versus ORIF in patients with proximal humeral fracture.

Methods

Patients with primary diagnosis of closed proximal humeral fracture undergoing either hemiarthroplasty or ORIF were selected from Nationwide Inpatient Sample databases for 1990–2000 (n = 10,306).

Results

Among white patients with proximal humeral fracture, 35.3% underwent hemiarthroplasty when compared with 17.2% of black and 26.9% of Hispanic patients (P < 0.001). Results of multivariate analysis adjusted for age, sex, hospital volume, year, and site of fracture on proximal humerus confirmed that black patients were less likely to undergo hemiarthroplasty when compared with white patients (OR = 0.76; 95% CI = 0.54, 1.08).

Conclusions

Our findings are consistent with studies documenting racial differences in utilization of elective orthopedic procedures. Given that humeral fracture is an emergency on most occasions, and our data suggest that differences in utilization more likely reflect surgeons’ operative decisions than patient preferences. We cannot ascertain whether differential procedure utilization is clinically justified. Further studies are needed to confirm whether surgeons’ operative decisions are a factor in the differential utilization of arthroplasty procedures by race and to understand outcomes and indications for ORIF and hemiarthroplasty, especially in black patients.

Keywords

Proximal humeral fractures Racial differences Hemiarthroplasty 

Supplementary material

590_2011_762_MOESM1_ESM.pdf (182 kb)
Supplementary material 1 (pdf 182 kb)

References

  1. 1.
    Epstein AM, Weissman JS, Schneider EC, Gatsonis C, Leape LL, Piana RN (2003) Race gender disparities in rates of cardiac revascularization: do they reflect appropriate use of procedures or problems in quality of care? Med Care 41(11):1240–1255PubMedCrossRefGoogle Scholar
  2. 2.
    Escalante A, Espinosa-Morales R, del Rincon I, Arroyo RA, Older SA (2000) Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care, socioeconomic status. Arthritis Rheum 43(2):390–399PubMedCrossRefGoogle Scholar
  3. 3.
    Escalante A, Barrett J, del Rincon I, Cornell JE, Phillips CB, Katz JN (2002) Disparity in total hip replacement affecting Hispanic Medicare beneficiaries. Med Care 40(6):451–460PubMedCrossRefGoogle Scholar
  4. 4.
    Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L (1993) Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med 118(8):593–601PubMedGoogle Scholar
  5. 5.
    Jones A, Kwoh CK, Kelley ME, Ibrahim SA (2005) Racial disparity in knee arthroplasty utilization in the veterans health administration. Arthritis Rheum 53(6):979–981PubMedCrossRefGoogle Scholar
  6. 6.
    Katz BP, Freund DA, Heck DA et al (1996) Demographic variation in the rate of knee replacement: a multi-year analysis. Health Serv Res 31(2):125–140PubMedGoogle Scholar
  7. 7.
    Mahomed NN, Barrett JA, Katz JN et al (2003) Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 85-A(1):27–32PubMedGoogle Scholar
  8. 8.
    Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E (2005) Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am 87(6):1222–1228PubMedCrossRefGoogle Scholar
  9. 9.
    McBean AM, Gornick M (1994) Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. Health Care Financ Rev 15(4):77–90PubMedGoogle Scholar
  10. 10.
    Peterson ED, Wright SM, Daley J, Thibault GE (1994) Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA 271(15):1175–1180PubMedCrossRefGoogle Scholar
  11. 11.
    Schneider EC, Leape LL, Weissman JS, Piana RN, Gatsonis C, Epstein AM (2001) Racial differences in cardiac revascularization rates: does “overuse” explain higher rates among white patients? Ann Intern Med 135(5):328–337PubMedGoogle Scholar
  12. 12.
    Schneider EC, Zaslavsky AM, Epstein AM (2002) Racial disparities in the quality of care for enrollees in medicare managed care. JAMA 287(10):1288–1294PubMedCrossRefGoogle Scholar
  13. 13.
    Skinner J, Weinstein JN, Sporer SM, Wennberg JE (2003) Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med 349(14):1350–1359PubMedCrossRefGoogle Scholar
  14. 14.
    Gregory PC, Han E, Morozova O, Kuhlemeier KV (2006) Do racial disparities exist in access to inpatient stroke rehabilitation in the state of Maryland? Am J Phys Med Rehabil 85(10):814–819PubMedCrossRefGoogle Scholar
  15. 15.
    Gregory PC, LaVeist TA, Simpson C (2006) Racial disparities in access to cardiac rehabilitation. Am J Phys Med Rehabil 85(9):705–710PubMedCrossRefGoogle Scholar
  16. 16.
    Byrne MM, O’Malley KJ, Suarez-Almazor ME (2004) Ethnic differences in health preferences: analysis using willingness-to-pay. J Rheumatol 31(9):1811–1818PubMedGoogle Scholar
  17. 17.
    Fiscella K, Franks P, Clancy CM (1998) Skepticism toward medical care and health care utilization. Med Care 36(2):180–189PubMedCrossRefGoogle Scholar
  18. 18.
    Guendelman S, Schwalbe J (1986) Medical care utilization by Hispanic children. How does it differ from black and white peers? Med Care 24(10):925–940PubMedCrossRefGoogle Scholar
  19. 19.
    Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK (2002) Differences in expectations of outcome mediate African American/white patient differences in “willingness” to consider joint replacement. Arthritis Rheum 46(9):2429–2435PubMedCrossRefGoogle Scholar
  20. 20.
    Jordan JM (1999) Effect of race and ethnicity on outcomes in arthritis and rheumatic conditions. Curr Opin Rheumatol 11(2):98–103PubMedCrossRefGoogle Scholar
  21. 21.
    Mutchler JE, Burr JA (1991) Racial differences in health and health care service utilization in later life: the effect of socioeconomic status. J Health Soc Behav 32(4):342–356PubMedCrossRefGoogle Scholar
  22. 22.
    Newacheck PW, Hughes DC, Stoddard JJ (1996) Children’s access to primary care: differences by race, income, and insurance status. Pediatrics 97(1):26–32PubMedGoogle Scholar
  23. 23.
    Potosky AL, Breen N, Graubard BI, Parsons PE (1998) The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey. Med Care 36(3):257–270PubMedCrossRefGoogle Scholar
  24. 24.
    Skinner J, Weinstein JN, Sporer SM, Wennberg JE (2003) Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med 349(14):1350–1359PubMedCrossRefGoogle Scholar
  25. 25.
    Suarez-Almazor ME, Souchek J, Kelly PA et al (2005) Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med 165(10):1117–1124PubMedCrossRefGoogle Scholar
  26. 26.
    Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF (1990) Access to medical care for children and adolescents in the United States. Pediatrics 86(5):666–673PubMedGoogle Scholar
  27. 27.
    Gerber C, Werner CM, Vienne P (2004) Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br 86(6):848–855PubMedCrossRefGoogle Scholar
  28. 28.
    Kralinger F, Schwaiger R, Wambacher M et al (2004) Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. J Bone Joint Surg Br 86(2):217–219PubMedCrossRefGoogle Scholar
  29. 29.
    Mighell MA, Kolm GP, Collinge CA, Frankle MA (2003) Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 12(6):569–577PubMedCrossRefGoogle Scholar
  30. 30.
    Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE (2003) Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am 85-A(7):1215–1223PubMedGoogle Scholar
  31. 31.
    Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK (2002) Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 84-A(11):1919–1925PubMedGoogle Scholar
  32. 32.
    Rees J, Hicks J, Ribbans W (1998) Assessment and management of three-and four-part proximal humeral fractures. Clin Orthop Relat Res 353:18–29PubMedCrossRefGoogle Scholar
  33. 33.
    Agency for Healthcare Research and Quality (2004) HCUP NIS database documentation Healthcare cost and utilization project (HCUP). Available at: http://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. Accessed 26 Dec 2004
  34. 34.
    Agency for Healthcare Research and Quality (2004) HCUP NIS database documentation Healthcare cost and utilization project (HCUP). Available at: http://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. Accessed 26 Dec 2004
  35. 35.
    Agency for Healthcare Research and Quality (2004) HCUP Quality Control Procedures, pp 2–3. Available at: http://www.ahrq.gov/data/hcup/sasddocu/techsupp2.pdf. Accessed 26 Dec 2004
  36. 36.
    Whalen D, Houchens R, Elixhauser A (2004) Final 2000 NIS Comparison Report HCUP Methods Series Report #2003-1 Agency for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq.gov/reports/2000NISComparisonReportFinal.pdf. Accessed 26 Dec 2004
  37. 37.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383PubMedCrossRefGoogle Scholar
  38. 38.
    Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45(6):613–619PubMedCrossRefGoogle Scholar
  39. 39.
    Escalante A, Espinosa-Morales R, del Rincon I, Arroyo RA, Older SA (2000) Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum 43(2):390–399PubMedCrossRefGoogle Scholar
  40. 40.
    Jain NB, Higgins LD, Ozumba D et al (2005) Trends in epidemiology of knee arthroplasty in the United States, 1990–2000. Arthritis Rheum 52(12):3928–3933PubMedCrossRefGoogle Scholar
  41. 41.
    Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN (2006) Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990–2000. Arthritis Rheum 55(4):591–597PubMedCrossRefGoogle Scholar
  42. 42.
    Jones A, Kwoh CK, Kelley ME, Ibrahim SA (2005) Racial disparity in knee arthroplasty utilization in the veterans health administration. Arthritis Rheum 53(6):979–981PubMedCrossRefGoogle Scholar
  43. 43.
    Katz BP, Freund DA, Heck DA et al (1996) Demographic variation in the rate of knee replacement: a multi-year analysis. Health Serv Res 31(2):125–140PubMedGoogle Scholar
  44. 44.
    Mahomed NN, Barrett JA, Katz JN et al (2003) Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 85-A(1):27–32PubMedGoogle Scholar
  45. 45.
    Schulman KA, Berlin JA, Harless W et al (1999) The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med 340(8):618–626PubMedCrossRefGoogle Scholar
  46. 46.
    Rathore SS, Lenert LA, Weinfurt KP et al (2000) The effects of patient sex and race on medical students’ ratings of quality of life. Am J Med 108(7):561–566PubMedCrossRefGoogle Scholar
  47. 47.
    Weisse CS, Sorum PC, Sanders KN, Syat BL (2001) Do gender and race affect decisions about pain management? J Gen Intern Med 16(4):211–217PubMedCrossRefGoogle Scholar
  48. 48.
    Abreu JM (1999) Conscious and nonconscious African American stereotypes: impact on first impression and diagnostic ratings by therapists. J Consult Clin Psychol 67(3):387–393PubMedCrossRefGoogle Scholar
  49. 49.
    Finucane TE, Carrese JA (1990) Racial bias in presentation of cases. J Gen Intern Med 5(2):120–121CrossRefGoogle Scholar
  50. 50.
    van Ryn M, Burke J (2000) The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 50(6):813–828PubMedCrossRefGoogle Scholar
  51. 51.
    Schulman KA, Berlin JA, Harless W et al (1999) The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med 340(8):618–626CrossRefGoogle Scholar
  52. 52.
    Jain N, Pietrobon R, Hocker S, Guller U, Shankar A, Higgins LD (2004) The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty. J Bone Joint Surg Am 86-A(3):496–505PubMedGoogle Scholar
  53. 53.
    Lane NE (2006) Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol 194(2 Suppl):S3–S11PubMedCrossRefGoogle Scholar
  54. 54.
    Villa ML, Nelson L (1996) Race, ethnicity, and osteoporosis. In: Marcus R, Feldman D, Kelsey J (eds) Osteoporosis. Academic Press, San Diego, pp 435–447Google Scholar
  55. 55.
    Koval KJ, Blair B, Takei R, Kummer FJ, Zuckerman JD (1996) Surgical neck fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques. J Trauma 40(5):778–783PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Nitin B. Jain
    • 1
  • Laurence D. Higgins
    • 2
  • Elena Losina
    • 2
    • 4
    • 5
  • Ricardo Pietrobon
    • 3
  • Jeffrey N. Katz
    • 2
    • 4
  1. 1.Department of Physical Medicine and RehabilitationSpaulding Rehabilitation Hospital and Harvard Medical SchoolBostonUSA
  2. 2.Department of Orthopaedic Surgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  3. 3.Department of Orthopaedic SurgeryDuke University Medical CenterDurhamUSA
  4. 4.Section of Clinical Sciences, Division of Rheumatology, Immunology, and AllergyBrigham and Women’s HospitalBostonUSA
  5. 5.Department of BiostatisticsBoston University School of Public HealthBostonUSA

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