Skip to main content
SpringerLink
Log in

Are African American Patients More Likely to Receive a Total Knee Arthroplasty in a Low-quality Hospital?

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Total joint arthroplasty is widely performed in patients of all races with severe osteoarthritis. Prior studies have reported that African American patients tend to receive total joint arthroplasties in low-volume hospitals compared with Caucasian patients, suggesting potential racial disparity in the quality of arthroplasty care.

Questions/purposes

We asked whether (1) a hospital outcome measure of risk-adjusted mortality or complication rate within 90 days of primary TKA can be directly used to profile hospital quality of care, and (2) African Americans were more likely to receive TKAs at low-quality hospitals (or hospitals with higher risk-adjusted outcome rate) compared with Caucasian patients.

Patients and Methods

We developed a risk-adjusted, 90-day postoperative outcome measure to identify high-, intermediate-, and low-quality hospitals based on patient records in the Medicare Provider Analysis and Review files between July 1, 2002, and June 30, 2005 (the first cohort). We then analyzed a second cohort of African American and Caucasian patients receiving Medicare who underwent primary TKAs between July and December 2005 to determine the independent impact of race on admissions to high-, intermediate-, and low-quality hospitals.

Results

The risk-adjusted postoperative mortality/complication rate varied substantially across hospitals; hospitals can be meaningfully categorized into quality groups. In the second cohort of admissions, 8% of African American patients (n = 4894) versus 9.2% of Caucasian patients (n = 86,705) were treated in high-quality hospitals whereas 14.7% of African American patients versus 12.7% of Caucasians patients were treated in low-quality hospitals. After controlling for patient demographic, socioeconomic, geographic, and diagnostic characteristics, the odds ratio for admission to low-quality hospitals was 1.28 for African American patients compared with Caucasian patients (95% CI, 1.18–1.41).

Conclusions

Among elderly Medicare beneficiaries undergoing TKA, African American patients were more likely than Caucasian patients to be admitted to hospitals with higher risk-adjusted postoperative rates of complications or mortality. Future work is needed to address the residential, social, and referring factors that underlie this disparity and implications for outcomes of care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Agresti A. Categorical Data Analysis. Ed 2. Hoboken, NJ: John Wiley & Sons Inc; 2002.

    Book  Google Scholar 

  2. American Hospital Association. AHA Data and Directories. Available at http://www.aha.org/aha/resource-center/Statistics-and-Studies/data-and-directories.html. Accessed August 17, 2011.

  3. Ash AS, Shwartz M, Pekoz EA. Comparing outcomes across providers. In: Iezzoni LI, ed. Risk Adjustment for Measuring Health Care Outcomes. Chicago, IL: Health Administration Press; 2003:297–334.

    Google Scholar 

  4. Bhattacharyya T, Freiberg AA, Mehta P, Katz JN, Ferris T. Measuring the report card: the validity of pay-for-performance metrics in orthopedic surgery. Health Aff (Millwood). 2009;28:526–532.

    Article  Google Scholar 

  5. Bhattacharyya T, Mehta P, Freiberg AA. Hospital characteristics associated with success in a pay-for-performance program in orthopaedic surgery. J Bone Joint Surg Am. 2008;90:1240–1243.

    Article  PubMed  Google Scholar 

  6. Centers for Disease Control and Prevention (CDC). Racial disparities in total knee replacement among Medicare enrollees—United States, 2000–2006. MMWR Morb Mortal Wkly Rep. 2009;58:133–138.

    Google Scholar 

  7. Cram P, Vaughan-Sarrazin MS, Rosenthal GE. Hospital characteristics and patient populations served by physician owned and non physician owned orthopedic specialty hospitals. BMC Health Serv Res. 2007;7:155.

    Article  PubMed  Google Scholar 

  8. Cram P, Vaughan-Sarrazin MS, Wolf B, Katz JN, Rosenthal GE. A comparison of total hip and knee replacement in specialty and general hospitals. J Bone Joint Surg Am. 2007;89:1675–1684.

    Article  PubMed  Google Scholar 

  9. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National Health Statistics Reports. US Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr005.pdf. Accessed August 2, 2011.

  10. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27.

    Article  PubMed  CAS  Google Scholar 

  11. Gaskin DJ, Hadley J. Population characteristics of markets of safety-net and non-safety-net hospitals. J Urban Health. 1999;76:351–370.

    Article  PubMed  CAS  Google Scholar 

  12. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511–520.

    PubMed  Google Scholar 

  13. Harris WH, Sledge CB. Total hip and total knee replacement (1). N Engl J Med. 1990;323:725–731.

    Article  PubMed  CAS  Google Scholar 

  14. Harris WH, Sledge CB. Total hip and total knee replacement (2). N Engl J Med. 1990;323:801–807.

    Article  PubMed  CAS  Google Scholar 

  15. Iezzoni LI. The risks of risk adjustment. JAMA. 1997;278:1600–1607.

    Article  PubMed  CAS  Google Scholar 

  16. Iezzoni LI. Risk Adjustment for Measuring Health Care Outcomes. Chicago, IL: Health Administration Press; 2003.

    Google Scholar 

  17. Jain NB, Higgins LD, Ozumba D, Guller U, Cronin M, Pietrobon R, Katz JN. Trends in epidemiology of knee arthroplasty in the United States, 1990–2000. Arthritis Rheum. 2005;52:3928–3933.

    Article  PubMed  Google Scholar 

  18. Jha AK, Fisher ES, Li Z, Oray EJ, Epstein AM. Racial trends in the use of major procedures among the elderly. N Engl J Med. 2005;353:683–691.

    Article  PubMed  CAS  Google Scholar 

  19. Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004;86:1909–1916.

    Article  PubMed  Google Scholar 

  20. Katz JN, Bierbaum BE, Losina E. Case mix and outcomes of total knee replacement in orthopaedic specialty hospitals. Med Care. 2008;46:476–480.

    Article  PubMed  Google Scholar 

  21. Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2001;83:1622–1629.

    Article  PubMed  Google Scholar 

  22. Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health. 1992;82:703–710.

    Article  PubMed  CAS  Google Scholar 

  23. Krumholz HM, Wang Y, Mattera JA, Han LF, Ingber MJ, Roman S, Normand SL. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction. Circulation. 2006;113:1683–1692.

    Article  PubMed  Google Scholar 

  24. Krumholz HM, Wang Y, Mattera JA, Han LF, Ingber MJ, Roman S, Normand SL. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure. Circulation. 2006;113:1693–1701.

    Article  PubMed  Google Scholar 

  25. Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87:1487–1497.

    Article  PubMed  Google Scholar 

  26. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.

    Article  PubMed  Google Scholar 

  27. Li Y, Glance LG, Cai X, Mukamel DB. Are patients with coexisting mental disorders more likely to receive CABG surgery from low-quality cardiac surgeons? The experience in New York State. Med Care. 2007;45:587–593.

    Article  PubMed  Google Scholar 

  28. Losina E, Barrett J, Baron JA, Levy M, Phillips CB, Katz JN. Utilization of low-volume hospitals for total hip replacement. Arthritis Rheum. 2004;51:836–842.

    Article  PubMed  Google Scholar 

  29. Losina E, Barrett J, Mahomed NN, Baron JA, Katz JN. Early failures of total hip replacement: effect of surgeon volume. Arthritis Rheum. 2004;50:1338–1343.

    Article  PubMed  Google Scholar 

  30. Losina E, Wright EA, Kessler CL, Barrett JA, Fossel AH, Creel AH, Mahomed NN, Baron JA, Katz JN. Neighborhoods matter: use of hospitals with worse outcomes following total knee replacement by patients from vulnerable populations. Arch Intern Med. 2007;167:182–187.

    Article  PubMed  Google Scholar 

  31. Manley M, Ong K, Lau E, Kurtz SM. Total knee arthroplasty survivorship in the United States Medicare population: effect of hospital and surgeon procedure volume. J Arthroplasty. 2009;24:1061–1067.

    Article  PubMed  Google Scholar 

  32. Mukamel DB, Weimer DL, Mushlin AI. Referrals to high-quality cardiac surgeons: patients’ race and characteristics of their physicians. Health Serv Res. 2006;41:1276–1295.

    PubMed  Google Scholar 

  33. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295:1912–1920.

    Article  PubMed  CAS  Google Scholar 

  34. Phibbs CS, Luft HS. Correlation of travel time on roads versus straight line distance. Med Care Res Rev. 1995;52:532–542.

    Article  PubMed  CAS  Google Scholar 

  35. Research Data Assistance Center. Medicare documentation. Available at http://www.resdac.org/ddvh/index.asp. Accessed August 17, 2011.

  36. Rural Health Research Center. RUCA Data version 2.0. Available at: http://depts.washington.edu/uwruca/ruca-data.php. Accessed August 2, 2011.

  37. Sarrazin MV, Campbell M, Rosenthal GE. Racial differences in hospital use after acute myocardial infarction: does residential segregation play a role? Health Aff (Millwood). 2009;28:w368–w378.

    Article  Google Scholar 

  38. Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359.

    Article  PubMed  CAS  Google Scholar 

  39. Suarez-Almazor ME, Souchek J, Kelly PA, O’Malley K, Byrne M, Richardson M, Pak C. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165:1117–1124.

    Article  PubMed  Google Scholar 

  40. US Census Bureau. Census 2000. Available at http://www.census.gov/main/www/cen2000.html. Accessed August 17, 2011.

  41. US Department of Health and Human Services. Hospital Compare. Available at: www.hospitalcompare.hhs.gov. Accessed May 17, 2011.

  42. Werner RM, Bradlow ET. Relationship between Medicare’s hospital compare performance measures and mortality rates. JAMA. 2006;296:2694–2702.

    Article  PubMed  CAS  Google Scholar 

  43. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42:121–130.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgment

We thank Carrie L. Franciscus for database maintenance.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, C44-Q GH, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Xueya Cai PhD, Peter Cram MD, MBA & Mary Vaughan-Sarrazin PhD

  2. Iowa City VA Medical Center, Iowa City, IA, USA

    Xueya Cai PhD, Peter Cram MD, MBA & Mary Vaughan-Sarrazin PhD

Authors
  1. Xueya Cai PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter Cram MD, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mary Vaughan-Sarrazin PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Xueya Cai PhD.

Additional information

One of the authors (PC) was supported by a K23 career development award (RR01997201) from the National Center for Research Resources at the National Institutes of Health and the Robert Wood Johnson Physician Faculty Scholars Program. One or more of the authors (PC) also was supported by R01 HL085347-01A1 from the National Heart, Lung, and Blood Institute at the National Institutes of Health. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Cai, X., Cram, P. & Vaughan-Sarrazin, M. Are African American Patients More Likely to Receive a Total Knee Arthroplasty in a Low-quality Hospital?. Clin Orthop Relat Res 470, 1185–1193 (2012). https://doi.org/10.1007/s11999-011-2032-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-011-2032-6

Keywords

Search

Navigation