Previous studies have addressed racial/ethnic and socioeconomic disparities in total knee arthroplasty (TKA) within the Medicare population. However, there is limited research examining these disparities across racial/ethnic and socioeconomic groups in the general population. This study used administrative data from the State Inpatient Databases from the Healthcare Cost and Utilization Project for the years 2007–2014 from California (2007–2011 only), Florida, New York, and Maryland (2012–2014 only). In all, 739,857 TKA readmission-eligible patients aged ≥8 years were included in the analysis. Black patients and patients with Medicaid had a higher likelihood of 30- and 90-day readmissions compared to white patients and patients with private insurance, respectively. Patients living in higher median income areas and patients treated at higher volume hospitals had lower likelihoods of 30- and 90-day readmissions compared to patients in the lowest median income quartile and patients treated at the lowest volume hospitals, respectively. These results confirmed racial/ethnic and socioeconomic disparities in TKA readmissions across 4 geographically diverse states, identified public insurance status as the salient factor across subpopulations, and raise awareness of the existence of these disparities outside of the Medicare population.
Get full access to this article
View all access options for this article.
References
1.
WeinsteinAM, RomeBN, ReichmannWM, et al.Estimating the burden of total knee replacement in the United States. J Bone Joint Surg Am, 2013; 95:385–392.
2.
MartinGM. Patient education: total knee replacement (arthroplasty) (Beyond the Basics). 2017. https://www.uptodate.com/contents/total-knee-replacement-arthroplasty-beyond-the-basics Accessed October9, 2017.
3.
KurtzS, OngK, LauE, MowatF, HalpernM. 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.
4.
QasimM, AndrewsRM. Post-surgical readmissions among patients living in the poorest communities, 2009. Statistical Brief# 142. Rockville, MD: Agency for Healthcare Research and Quality, 2006.
5.
Centers for Medicare & Medicaid Services.. Readmissions Reduction Program (HRRP). 2016. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Accessed October9, 2017.
DuGoffEH, BishopSM, RawalP. Hospital readmission reduction program reignites debate over risk adjusting quality measures. 2014. https://www.healthaffairs.org/do/10.1377/hblog20140814.040725/full/ Accessed January8, 2018.
8.
RauJ. Hospital treating the poor hardest hit by readmissions penalties. Kaiser Health News. 2012. https://khn.org/news/hospitals-treating-poor-hardest-hit-readmissions-penalties/ Accessed May28, 2018.
9.
McHughMD, CarthonJM, KangXL. Medicare readmissions policies and racial and ethnic health disparities: a cautionary tale. Policy Polit Nurs Pract, 2010; 11:309–316.
10.
SkinnerJ, WeinsteinJN, SporerSM, WennbergJE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med, 2003; 349:1350–1359.
11.
MahomedNN, BarrettJ, KatzJN, BaronJA, WrightJ, LosinaE. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am, 2005; 87:1222–1228.
12.
XuHF, WhiteRS, SastowDL, AndreaeMH, Gaber-BaylisLK, TurnbullZA. Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York. J Clin Anesth, 2017; 43:24–32.
13.
D'ApuzzoM, WestrichG, HidakaC, Jung PanT, LymanS. All-cause versus complication-specific readmission following total knee arthroplasty. J Bone Joint Surg Am, 2017; 99:1093–1103.
14.
ZhangW, LymanS, Boutin-FosterC, et al.Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty. J Bone Joint Surg Am, 2016; 98:1243–1252.
15.
SooHooNF, ZingmondDS, KoCY. Disparities in the utilization of high-volume hospitals for total knee replacement. J Natl Med Assoc, 2008; 100:559–564.
16.
LiuJH, ZingmondDS, McGoryML, et al.Disparities in the utilization of high-volume hospitals for complex surgery. JAMA, 2006; 296:1973–1980.
17.
SooHooNF, ZingmondDS, LiebermanJR, KoCY. Primary total knee arthroplasty in California 1991 to 2001: does hospital volume affect outcomes?. J Arthroplasty, 2006; 21:199–205.
18.
JeschkeE, CitakM, GunsterC, et al.Are TKAs performed in high-volume hospitals less likely to undergo revision than TKAs performed in low-volume hospitals?. Clin Orthop Relat Res, 2017; 475:2669–2674.
19.
KatzJN, BarrettJ, MahomedNN, BaronJA, WrightRJ, LosinaE. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am, 2004; 86:1909–1916.
20.
HerveySL, PurvesHR, GullerU, TothAP, VailTP, PietrobonR. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-nationwide inpatient sample. J Bone Joint Surg Am, 2003; 85:1775–1783.
Healthcare Cost and Utilization Project. Overview of the State Inpatient Databases. https://www.hcup-us.ahrq.gov/sidoverview.jsp Accessed November17, 2017.
23.
MemtsoudisSG, MaY, Gonzalez Della ValleA, et al.Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology, 2009; 111:1206–1216.
24.
van WalravenC, AustinPC, JenningsA, QuanH, ForsterAJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care, 2009; 47:626–633.
25.
ClendennenSL, BowdenRG, GriggsJO, MorganGB, Umstattd MeyerMR. Risk factors associated with the timing of hospital readmission in an underserved low socioeconomic population. Hosp Pract (1995), 2015; 43:284–289.
26.
RaviP, SoodA, SchmidM, et al.Racial/ethnic disparities in perioperative outcomes of major procedures: results from the National Surgical Quality Improvement Program. Ann Surg, 2015; 262:955–964.
27.
AdelaniMA, KellerMR, BarrackRL, OlsenMA. The impact of hospital volume on racial differences in complications, readmissions, and emergency department visits following total joint arthroplasty. J Arthroplasty, 2018; 33:309–315.e20.
28.
HawkinsK, EscotoKH, OzminkowskiRJ, BhattaraiGR, MiglioriRJ, YehCS. Disparities in major joint replacement surgery among adults with Medicare supplement insurance. Popul Health Manag, 2011; 14:231–238.
29.
KurtzSM, OngKL, LauE, BozicKJ, BerryD, ParviziJ. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res, 2010; 468:52–56.
30.
CalderwoodMS, KleinmanK, HuangSS, MurphyMV, YokoeDS, PlattR. Surgical site infections: volume-outcome relationship and year-to-year stability of performance rankings. Med Care, 2017; 55:79–85.
31.
CramP, HawkerG, MatelskiJ, et al.Disparities in knee and hip arthroplasty outcomes: an observational analysis of the ACS-NSQIP clinical registry. J Racial Ethn Health Disparities, 2018; 5:151–161.
32.
SinghJA, KwohCK, RichardsonD, ChenW, IbrahimSA. Sex and surgical outcomes and mortality after primary total knee arthroplasty: a risk-adjusted analysis. Arthritis Care Res (Hoboken), 2013; 65:1095–1102.
33.
KheirMM, ClementRC, DermanPB, et al.Are there identifiable risk factors and causes associated with unplanned readmissions following total knee arthroplasty?. J Arthroplasty, 2014; 29:2192–2196.
34.
HartA, AntoniouJ, BrinYS, HukOL, ZukorDJ, BergeronSG. Simultaneous bilateral versus unilateral total knee arthroplasty: a comparison of 30-day readmission rates and major complications. J Arthroplasty, 2016; 31:31–35.
ZuckermanRB, SheingoldSH, OravEJ, RuhterJ, EpsteinAM. Readmissions, observation, and the hospital readmissions reduction program. N Engl J Med, 2016; 374:1543–1551.
37.
ShihT, RyanAM, GonzalezAA, DimickJB. Medicare's hospital readmissions reduction program in surgery may disproportionately affect minority-serving hospitals. Ann Surg, 2015; 261:1027–1031.
38.
JoyntKE, FigueroaJE, OrayJ, JhaAK. Opinions on the hospital readmission reduction program: results of a national survey of hospital leaders. Am J Manag Care, 2016; 22:e287–e294.
39.
GuQ, KoenigL, FaerbergJ, SteinbergCR, VazC, WheatleyMP. The Medicare hospital readmissions reduction program: potential unintended consequences for hospitals serving vulnerable populations. Health Serv Res, 2014; 49:818–837.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
