CORR Synthesis: How Might the Preoperative Management of Risk Factors Influence Healthcare Disparities in Total Joint Arthroplasty?

Abstract

In the Beginning… The concept of identifying and treating patients’ comorbidities before surgery initially appeared in research on cardiothoracic surgery, with a focus on reducing risk factors that increase cardiac strain such as anemia, hypothyroidism, and diuretic use [13]. The goal was to prepare patients preoperatively to reduce the risk of a high-risk surgical intervention and to allow for earlier detection of complications. Over time, the concept of preoperative risk factor management has been extended to other procedures such as total joint arthroplasty (TJA), spine surgery, urologic surgery, and gastrointestinal surgery [17, 68, 78]. In orthopaedics, preoperative risk factor management in TJA has grown as an area of research, resulting in reduced readmissions, emergency department (ED) visits, length of stay (LOS), and overall costs as well as increased discharge to home after TJA [7, 19, 41]. Preoperative risk management programs in orthopaedics are evolving, and several models have been implemented to address risk factors before TJA. Some programs have focused on screening for risk factors preoperatively with recommended interventions when patients meet specific criteria, such as low hemoglobin levels, elevated hemoglobin A1c levels, and elevated BMI [7, 12, 19, 28, 41, 56]. Many of these programs also use dedicated “navigators”, who typically are nurses and social workers, to guide patients throughout the risk management process [7, 12, 19]. Other institutions simply implement preoperative surgical selection criteria without detailed guidance regarding the management of modifiable risk factors [50, 51]. The Argument Patients identifying as Black or Hispanic are more likely to have a postoperative complication, a longer LOS, a lower likelihood of home discharge, a visit to the ED, and be readmitted after TJA [3, 18, 53, 59, 69]. Although patients identifying as Black and Hispanic have experienced some improvement in LOS after TJA, when compared with White patients, disparities in complication rates and hospital readmissions still persist [5, 70, 73]. Women are more likely to stay longer in the hospital and have a postoperative complication following TJA; they are also less likely to be discharged home [14]. Similar findings of increased LOS, ED visits, and readmissions have been discovered when investigating the association between patients with lower incomes versus patients with higher incomes as well as Medicaid insurance compared with private insurance after TJA [20, 60, 61]. Additionally, patients with lower incomes face an increased risk of mortality and revision after THA than those with higher incomes [22]. However, race, ethnicity, gender, and income do not exist in isolation and the intersection of these factors also is associated with increased LOS [35, 36]. Understanding the disparities that patients from racial and ethnic minority backgrounds, women, and patients with lower incomes face related to readmissions, ED visits, complications, and LOS after TJA is critical to eliminating these disparities. Our review provides an overview of disparities in TJA related to race, ethnicity, gender, income, and insurance. Comprehensive preoperative risk management programs seek to reduce the frequency of readmissions and ED visits as well as to shorten LOS after TJA, and some have reported success in those areas [7, 19, 41]. However, we are concerned that these types of programs, by enforcing strict eligibility criteria without providing robust care management pathways to achieve cutoffs, may worsen access for TJA and may prevent participation in preoperative risk management programs for patients from racial and ethnic minority backgrounds, women, and patients with lower incomes [3, 74]. Additionally, comprehensive risk management programs decrease readmissions, ED vists, and LOS overall, but may not be providing those same benefits to patients from racial and ethnic minority backgrounds, women, and patients with lower incomes. Unconscious bias by orthopaedic surgeons may also result in surgeons being less likely to consider patients from racial and ethnic minority backgrounds, women compared with men, and patients with lower incomes as surgical candidates [23]. In addition, preoperative risk management programs sometimes rely on services provided by other specialties such as bariatric surgery, endocrinology, and cardiology to assist patients in reaching safer preoperative goals. As in orthopaedic surgery [1, 15, 40], insurance restrictions may impede patients’ access to care, and many of the same biases that have been observed in orthopaedic surgery in terms of access exist in those specialties, too [2, 31, 37, 71]. Some patients may also need additional assistance to prepare for surgery, such as guidance from social workers, nursing care coordinators, or substance use counselors. These services might not be offered by all orthopaedic practices and might not be accessible to all patients. Our review explores the use of preoperative cutoffs in preoperative risk management programs and the referral pathways for nonorthopaedic specialist care within these programs to determine how cutoffs and specialist referrals may be impacting patients from racial and ethnic minority backgrounds, women, patients with lower incomes, and patients with Medicaid. The goal of comprehensive risk management programs is to reduce the risk of postoperative complications, readmissions, ED visits, and reduce LOS; consequently, these programs should be implemented for all patients regardless of race, ethnicity, gender, or income. Given that patients from racial and ethnic minority backgrounds, women, and patients with lower incomes historically have had more frequent readmissions and ED visits, longer LOS, as well as decreased discharges home after TJA [14, 69, 76], our review investigates how comprehensive risk management programs may be associated with readmissions, ED visits, LOS, discharge disposition, and postoperative complications for these patient populations. Essential Elements We searched the Ovid MEDLINE and Embase databases for articles that covered the concepts of “arthroplasty”, “preoperative risk management”, and “healthcare disparities” (Supplementary Fig. 1; https://links.lww.com/CORR/A753). Given the relatively small number of articles our search returned (n = 98), we also searched through abstracts presented at the American Association of Orthopaedic Surgeons conferences from 2020 and 2021 and abstracts presented at the American Association of Hip and Knee Surgeons from 2013 through 2021 and found two articles of interest. Additionally, we performed citation chaining, defined as examining reference lists for additional studies and identifying articles that cited relevant studies, on articles related to preoperative risk management and found 12 relevant studies. We included studies if they were original research published after 2010, the operation of interest was elective TJA in adult patients. The included studies needed clinical data for the procedure of interest (THA, TKA, or both), and focused on more than one postoperative outcome such as LOS, readmissions, functional status, surgical site infection incidence, or ED visits. Specifically for studies describing associations between race, gender, insurance type, and income, we excluded studies with a sample size less than 10,000 patients. We could not apply this exclusion criterion for studies describing preoperative risk management programs because most of these studies were retrospective institutional studies. Regarding studies describing preoperative risk management programs, we only included programs that considered at least three patient factors such as anemia, obesity, and hemoglobin A1c level for potential modification and were not solely tools that investigated associations between specific risk factors and postoperative readmissions to estimate risk. We found 24 articles that met our inclusion criteria, 12 articles related to healthcare disparities and 12 related to preoperative risk management programs (Fig. 1).Fig. 1.: Literature search strategy and study selection process. aCriterion does not apply to studies describing preoperative risk management programs. bCriterion does not apply to studies describing healthcare disparities; AAHKS = American Association of Hip and Knee Surgeons; AAOS = American Academy of Orthopaedic Surgeons; TJA = total joint arthroplasty.Of the 12 articles related to disparities in care (Table 1), one study was related to preoperative risk factors and the time to TJA, number of patient comorbidities, in-hospital complications, and discharge disposition, specifically focusing on disparities in care for women [14]. Four studies investigated disparities in care for patients from ethnic and racial minority backgrounds: investigating the associations between race and ethnicity with procedure utilization, LOS, readmissions, and postoperative complications [18, 62, 70, 73]. Three studies investigated disparities in complications, LOS, discharge disposition, and readmissions for THA, and investigated race, gender, comorbidity burden, and insurance type [67, 75, 76]. In three studies, investigators explored the association between insurance type and disparities in mortality, complications, readmissions, and LOS after THA and TKA [47, 72, 77]. Finally, Holbert et investigated associations between in a and LOS, discharge disposition, readmissions, and ED visits. We the for criteria for studies to these 12 studies (Supplementary 1; The for studies the criteria is and the of studies related to disparities in care was to of studies found in search related to disparities in care number of patients type healthcare preoperative risk factor in care for women et THA and TKA study the a of preoperative risk factors and disparities patients TJA Women for TJA, have more comorbidities, more in-hospital complications, and are less likely to be discharged home compared with in care for patients from racial and ethnic minority et TKA study associations between race and ethnicity and procedure utilization, LOS, readmissions, and postoperative complications Black race compared with White race was associated with more readmissions, longer LOS, and of postoperative ethnicity compared with White patients was associated with longer LOS and of postoperative and et THA study in procedure utilization, comorbidity hospital LOS, mortality, readmissions, and complications, and risk factors for patients identifying as Black and have been in procedure utilization, comorbidity and LOS; in mortality, readmissions, or complications. that preoperative management of risk factors is a for intervention et TKA study in mortality, LOS, postoperative surgical and complications, and readmissions after TKA and a preoperative risk for Black patients TKA have been in in LOS, of and postoperative surgical complications for Black patients after The study also a risk for Black patients. management of risk factors preoperatively such as and use et TKA study in utilization, comorbidity hospital LOS, mortality, readmissions, and complications patients identifying as and have been in procedure utilization, comorbidity and LOS, but the of postoperative and stay have and that preoperative management of risk factors could be for this patient in care on race, gender, comorbidity burden, and insurance type et THA study data patient and factors that are associated with complications after THA The found that the of complications after THA, and revision was associated with at Black race, and patients with more et THA study patient associated with LOS and discharge The found that gender, compared with was associated with LOS and Black race, compared with White race was associated with LOS and Medicaid insurance was associated with LOS LOS and race, and insurance that preoperative risk management programs may patients to be excluded White et THA study and in by insurance race or ethnicity, and income The found that Medicaid insurance compared with private Black race compared with White race, and lower incomes compared with higher incomes are associated with higher income, and insurance modifiable risk factors preoperatively in care on insurance type et TKA study and insurance type is associated with in-hospital mortality and after TKA Medicaid insurance is associated with an increased of mortality and complications after type and et TKA study the the association between patient insurance type and in-hospital complications after TKA The found that insurance or is associated with more complications and race compared with White race is associated with complications after type and that preoperative risk factor management is to reduce modifiable risk factors before surgery et THA study and the between insurance type and in-hospital mortality, postoperative complications, readmissions, and LOS after THA The found that Medicaid insurance compared with private insurance is associated with increased in-hospital mortality, and complications, readmissions, and LOS type and in care, other Holbert et THA and TKA institutional study associations between in a area and LOS, discharge disposition, readmissions, and ED visits The found that in a area was associated with longer LOS, discharge, increased and increased ED visits that patients were for in a and preoperative = = American of Surgeons = = ED = emergency We found an additional 12 studies that the of comprehensive preoperative risk management programs (Table [7, 12, 19, 41, We the criteria for studies to these 12 studies (Supplementary The for studies the criteria is and the of studies related to preoperative risk management programs was to As citation is not as comprehensive as a is that we some studies related to this and we this may be a of our However, that we performed citation in to our comprehensive we do not that we relevant studies that have the findings of our describing comprehensive preoperative risk management programs number of patients type eligibility for eligibility healthcare et THA and TKA institutional study the of a preoperative risk factor management on postoperative LOS, readmissions, discharge disposition, and The found that the preoperative decreased LOS and and was in discharge or BMI or between if additional comorbidity and recommended additional for other and of race, gender, or income related to disparities in insurance type could not be for et THA and TKA institutional study of a to decrease after THA or TKA of the to risk factors was associated with a decreased of after BMI and of race, gender, income, or insurance type related to disparities in care et THA and TKA institutional study associations between of a preoperative risk factor management and LOS, ED visits, and readmissions following THA or TKA of the was associated with reduced LOS and ED visits. BMI and of race, gender, income, or insurance type related to disparities in care et THA institutional study association between of a care for THA with LOS, discharge disposition, complications, and of the was associated with reduced LOS, an increase in home and decreased of the was not associated with in complications. BMI and White race were associated with reduced LOS and increased home discharges but not disparities in found that insurance was associated with increased LOS, decreased home discharge, and increased complications but not disparities in of income et TKA institutional study association between of a care for TKA with LOS, discharge disposition, complications, and of the was associated with decreased LOS, increased home and reduced of the was not associated with in complications. as study and White race were associated with reduced LOS and increased home discharge but do not disparities in race was associated with increased found that insurance is associated with increased LOS, decreased home discharge, and increased of income et THA and TKA institutional study association between of and discharge disposition, complications, readmissions, and LOS of was associated with reduced increased home decreased readmissions, complications, and of race, gender, income, or insurance type related to disparities in care et THA and TKA institutional study the association between a preoperative risk management and postoperative readmissions, discharge LOS, and infection of this was associated with lower and lower of discharge to a care BMI and of race, gender, or insurance type related to disparities in that was not be associated with discharge et THA and TKA institutional study of preoperative screening criteria was associated with reduced complications and of the preoperative screening criteria was associated with reduced total complications and BMI hemoglobin and of race, gender, or income related to disparities in included patients at et THA institutional study of the and associations with surgery time, discharge disposition, LOS, and costs of the was associated with reduced LOS and increased home was not associated with in surgery time, readmissions, or BMI and hemoglobin that increased of patient selection may to disparities in of disparities in care specific to race, gender, income, or insurance type et TKA institutional study of and association with surgery time, LOS, discharge disposition, and costs of the was associated with decreased LOS and increased home was not associated with surgery time or BMI and hemoglobin that in of patients TKA before and after of of disparities in care related to race, gender, income, or insurance type et TKA study association of a preoperative with LOS, discharge disposition, ED visits, and readmissions at a was associated with reduced LOS and discharges to was not associated with ED visits or BMI and hemoglobin and related to and of race, gender, or income related to disparities in only included patients with insurance et THA and TKA institutional study the association between of an and LOS, complications, discharge disposition, and of the was associated with reduced LOS, increased home reduced complications, and reduced for BMI that lower income is associated with disparities in access to TJA in and that as a patient has lower incomes. was of race, gender, or insurance types related to disparities in = hemoglobin = joint ED = emergency = Comprehensive for = = surgical site = = nursing We We We found that an increased risk of mortality, complications, readmissions, longer LOS, and less functional improvement are observed patients from racial and ethnic minority backgrounds, women compared with men, and patients with lower incomes (Table [14, 18, 62, 72, Many potential for these disparities have been offered in studies patient functional status, LOS, readmissions, and discharge home after TJA, status, in care, and insurance type 69, 76]. Although these factors may to disparities in care, race, gender, income, and insurance type should not be as risk factors in TJA because they are not of LOS, readmissions, ED visits, functional status, and postoperative complication rates Some studies have this and found that Black patients and women have functional and compared with White patients and after TJA, when with more and more comorbidities preoperatively research has that race is not associated with for most and functional after TKA, and that Black patients and White patients are to be considered for TJA, these studies had sample than those included in our search The intersection Medicaid gender, and race or ethnicity may the in LOS, readmissions, and ED visits in these patients 76]. potential in many of the studies found in our review is the of patient As research has patients from racial and ethnic minority and patients with Medicaid have been considered because they are more likely to with comorbidities [47, 72, 77]. In clinical tools such as risk have been to the risk of after THA or TKA that to patients who as patients with lower incomes, and patients by Medicaid models were in TJA to reduce costs and the of care for patients these may be surgeons from on patients with a number of comorbidities Preoperative risk management programs were implemented to in modifiable risk factors that be preoperatively to reduce the likelihood of complications surgical site and joint readmissions, LOS, and as well as reduced costs [7, 12, 19, 41, These programs focus on modifiable risk factors such as obesity, anemia, and substance use and or referrals for these factors these risk some programs rely on cutoffs for BMI and hemoglobin A1c that may prevent patients from surgery 74]. the 12 programs we found describing preoperative risk management programs (Table specifically included recommended for hemoglobin A1c [7, 12, 19, 41, and included recommended for BMI [7, 12, 19, 41, The in recommended in these studies from to for hemoglobin A1c and to for BMI the of these preoperative risk management programs have been to reduce length of stay and readmissions, these programs have not performed by race to specific on patients from racial and ethnic minority backgrounds, women, and patients with lower incomes [7, 12, 19, 41]. The use of such programs to reduce the risk of postoperative complications patient in the preoperative These programs should also the that patients from racial and ethnic minority backgrounds, women, patients with lower incomes, and patients by Medicaid need additional However, the use of preoperative risk management programs, patients from racial and ethnic minority backgrounds, patients with lower incomes, and patients who are by programs that low for services do not access services such as management and et found that only of patients for a referral for preoperative was recommended for anemia, endocrinology, or cardiology a referral to the The studies we found related to preoperative risk management programs (Table not to the success of referrals to [7, 12, 19, 41, referral pathways and preoperative risk management a to TJA, and to the for patients from racial or ethnic minority and patients with lower incomes to preoperative Preoperative risk management programs not achieve without and referral that allow patients to for and research has been on how preoperative risk management programs postoperative LOS, readmissions, ED visits, and complications for patients from racial and ethnic minority backgrounds, women, patients with lower incomes, or patients by are many in our the 12 studies we found preoperative risk management programs (Table performed by race, gender, or income level to the of preoperative risk management programs [7, 12, 19, 41, one of the 12 studies, et that preoperative risk management programs may to care to patients with lower incomes or who have a number of et also the patient before and after of Comprehensive for and found before and after but they only at gender, and et in the that patient income was not included but be to in studies. patient one study only included patients one study was at a hospital and study patient data and was to patient insurance type The studies describing preoperative risk management programs (Table not patient insurance studies by et found that with and White race with other than were associated with reduced LOS and increased home and insurance was associated with increased LOS, decreased home and increased complications. However, these studies not how this to disparities in care and not to these et that as is a they may be more likely to have patients with lower incomes and that lower incomes be associated with disparities in but they do not to Many of these studies were at an institutional a by race, gender, income, or insurance type may not have been because of sample research on this is to that these programs are not healthcare disparities in readmissions, ED visits, and LOS after TJA for patients from racial and ethnic minority backgrounds, women, patients with lower incomes, and patients with who are the most in need of TJA. We found in preoperative risk management programs. the studies that for preoperative BMI and hemoglobin only one provides specific to studies to the Additionally, only one of the 12 studies we found related to preoperative risk management programs that these programs could access to care for patients Preoperative risk management programs may on patients that from TJA, such as cutoffs for BMI and hemoglobin A1c These restrictions patients with lower incomes and patients from racial or ethnic minority strict cutoffs without a comprehensive of the patient that the of and an of the factors that patient care is an and research the of these cutoffs, within preoperative risk management programs, is to patients are we the of the preoperative risk management on patients from racial and ethnic minority backgrounds, women, patients with lower incomes, and patients with Medicaid insurance. these programs do not of an risk level for the patient to with surgery, the of patients who have or the length of time patients in the before Although preoperative risk management programs have LOS, reduced and ED visits, and reduced postoperative complications [7, 12, 19, 41, these were not by race, gender, income, or insurance type, and we are to if associations between race, gender, income, or insurance type and these studies found that after of these programs, race, gender, and insurance type were associated with in LOS, discharge disposition, and complications they not the potential of these findings or to may that preoperative risk management programs LOS, discharge disposition, readmissions, and postoperative complications for White patients with higher incomes, but do not benefits of a for patients from racial and ethnic minority backgrounds, women, patients with and patients with lower incomes. and to related to the and of preoperative risk management programs may be these programs from potential benefits in terms of TJA we that cutoffs for hemoglobin and should be surgeons should with patients in and increased patient regarding of TJA and for management of these risk factors Preoperative risk management programs should to patients throughout the management process to that they are on and have the to meet before with additional regarding of preoperative risk management programs is from the for Medicaid such as only the of postoperative LOS, readmissions, and complications of the pathways to achieve in these and in preoperative risk management be more are to that of preoperative risk management programs the needed for related to of preoperative risk management programs the in race, ethnicity, and income as well as the sample size to with these same Orthopaedic surgeons should practices are and race, ethnicity, and income for patients who seek for management of and Given that many of the preoperative risk management programs we found were implemented relatively we these to with data to sample to by race, ethnicity, gender, income, and insurance orthopaedic surgeons who to implement preoperative risk management programs, we programs to related to that they more research the associations between race, ethnicity, gender, income, and insurance type and programs (Table We have a of for two of and a more robust for preoperative risk management programs (Table The from additional that are more to These are patient patient and surgical several of these a of patient we the detailed in a review the and of risk tools that be to and discharge after TJA. The tools included in the review are the the American of Surgeons the the the the the the and the and the for to preoperative risk factor management programs for patient should be factors patient risk level to with surgery if to with as or of patient risk the risk of patient risk at risk at factors for and of patients for management is recommended surgery on risk of patients in who TJA after in the risk management time patients in before TJA number of referrals to patient number of referrals to specialist patient time in to a specialist or or endocrinology, and with social programs that Medicaid or patients substance or social factors versus surgery LOS needed home or or for postoperative and readmissions and ED visits of outcome to review by et for = LOS = length of = postoperative = hemoglobin = nursing = ED = emergency = surgical site We that three factors preoperative risk management programs more in the the to models by a focus on preoperative management to reduce LOS, readmissions, ED visits, and postoperative complications. as more are performed in the these programs patients are most likely to and the procedure safer for we that for preoperative risk management and because of more orthopaedic practices preoperative risk factor care