One of the many challenges that orthopaedic surgeons face today is evaluating a patient as a whole by looking beyond a checklist that determines eligibility for surgery. When orthopaedic surgeons decline to perform joint replacements on patients with comorbidities, are underrepresented populations being disproportionately impacted? The data show the answer is yes.
Daniel Wiznia, MD, is a dual-appointed assistant professor affiliated with both the Department of Orthopaedics & Rehabilitation and the School of Engineering & Applied Science. He cares passionately about equity in health care and recently investigated urgent care accessibility, discovering in 2021 that new orthopedic urgent care centers avoid Medicaid patients.
Wiznia is also part of the nonprofit Movement is Life, a multi-disciplinary coalition that seeks to eliminate racial, ethnic, and gender disparities in muscle and joint health by improving quality of life among women who are African American, Hispanic/Latina, or live in rural communities. The organization’s community stakeholders, subject matter experts, and healthcare providers actively seek to eliminate racial and gender disparities in musculoskeletal health.
Most recently, Wiznia presented Grand Rounds at the schools of medicine for the University of Maryland, Northwestern, Howard University, Harbor-UCLA Medical Center, and Yale on the topic of wide-ranging disparities that exist in arthroplasty, otherwise known as joint replacement. Although the information he speaks to in the field of arthroplasty is sobering, the commitment to find actionable solutions and advance patient-centered care is well under way at Yale. Understanding those disparities is integral to ensuring the field of orthopaedics can continuously improve.
While joint replacement is often a surgical intervention to alleviate pain, regain function, and renew quality of life, the challenges often begin years earlier with arthritis. According to the CDC, a quarter of American adults— about 54 million people—have arthritis. The CDC estimates that 67 million Americans will have the condition by 2030. Cases of arthritis, however, are not distributed equally among genders, ages, and ethnicities.
According to a report from the Centers for Disease Control and Prevention, women are more adversely affected by arthritis than men. Women are 56% more likely than men to develop the condition and also have an 83% higher chance of disability due to arthritis. Most important, the disparity between men and women occurs at every age group evaluated.
Disparities related to arthritis go beyond gender. Data show that racial and ethnic minorities develop arthritis at younger ages. 54% of African American women are diagnosed with arthritis, compared to 37% of white women. The CDC report also showed that the prevalence of arthritis decreases as income rises.
As arthritis progresses, patients may seek to have a hip or knee replaced. That experience also comes with noted disparities.
“One of the main factors affecting access [to care] is that certain patient groups present later to clinics or for surgery,” Wiznia said. “Based on a study that was conducted by the University of Pennsylvania that examined total knee replacements, African American women waited nearly two years longer than white women to receive treatment.”
The delays, though, are two-fold. “Not only were these patients delayed in presenting to clinic,” Wiznia continued. “But African American women were additionally delayed by about 35% longer than white patients in receiving total joint replacement based on this study.
This trickles down even further to how each patient is feeling and what their unique level of function is by the time they ultimately seek medical help. “Worse function can also be observed prior to surgery,” Wiznia added. “Based on a cohort study that used the prospective Women’s Health Initiative data bank, it was revealed that Black women who were about to undergo total knee replacement had poorer physical function than white women during the decade before surgery.”
Furthermore, the gender of a patient can often play a role in determining whether a physician will even recommend total knee replacement surgery. Wiznia noted a mystery shopper study out of Canada, which was conducted unbeknownst to the surgeons. As part of this style of research, female and male patients presented to 67 different physicians with moderate arthritis and the same levels of functional capacity, pain severity, amount of sleep disturbance, and use of pain medication. A total of 67% of physicians recommended total knee replacement to the male patient compared with only 33% who recommended the same surgical procedure to the female patient.
Disparities for minorities in surgical outcomes
“Ethnic minorities have higher rates of adverse health outcomes,” Wiznia said, citing a study from George Washington University that examined patient outcomes in eight states. “Over 10 years, in-hospital complication rates decreased for whites and remained unchanged for African Americans when comparing data from 2006 and 2015,” he said. “That, I believe, is largely attributable to social determinants of health.”
“Based on the same cohort, African American women also had poorer physical function than white women in the decade after total knee replacement surgery,” Wiznia added. “I think a large portion of the variance in outcomes is a comorbidity burden. It’s not uncommon for us to see patients who say something like: ‘I saw another orthopaedic surgeon a few years ago but they didn’t want to operate on me because I was too heavy and had diabetes. They said that the risk of surgery was too high and to go home and lose weight. I told them I have struggled with my weight my entire life but they didn’t seem to hear me or care.’”
If the patient was not a good candidate for total joint replacement, were these surgeons wrong for turning patients away?
Optimizing the preoperative process
“We know that comorbidities including heart failure, stroke, kidney disease, COPD are a factor that often increase a patient’s length of hospital stay,” Wiznia continued. “The concern is that if surgeons are going to refuse to operate on patients with comorbidities, will that disproportionately impact minorities? The answer is yes.”
He said, “The question that I believe we really need to ask is: as we strive to improve the health of our nation by paying doctors and hospitals for quality instead of quantity, are we leaving some patients behind?”
For Wiznia and others in the health system, this presents an opportunity for a preoperative optimization process, a concept that was initially coined in the American Journal for Cardiology in 1963. This effort includes assisting with areas of a patient’s health maintenance, such as diabetes, malnutrition, anemia, substance use, and more, with the goal to improve the modifiable risk factors and reduce likelihood of complications like infection and readmission.
“In a successful optimization program, you have to identify two things,” Wiznia said. “Which patient comorbidities impact complications and which of those comorbidities is actually modifiable and can be improved? We are very fortunate to have an incredible nurse navigator program at Yale that helps optimize our arthroplasty patients.”
There is a stark difference, however, between optimization programs and inflexible checklists used by physicians to serve as a clear delineation for those who are ruled in or out of surgical candidacy. In fact, according to a study conducted by Johns Hopkins University, eligibility criteria has proven to worsen disparities.
A Duke University study compared joint replacements at a checklist hospital and a non-checklist hospital. The checklist hospital did not reduce complications, emergency department visits, or readmissions associated with joint replacement. The non-checklist hospital saw longer lengths or stay and discharges to skilled nursing facilities. Interestingly, the checklist hospital only referred 35% of patients for assistance with comorbidities.
If patients are not good candidates for orthopaedic surgery, Wiznia urges physicians to ask what programs or resources are available. Opportunities abound—and are acted upon at Yale— to form collaborative partnerships with bariatric surgery, endocrinology, cardiology, hematology, nurse care coordinators, substance use counselors, and nutrition or weight loss support.
Wiznia is working with Movement is Life to publish a series of articles that will appear in the Journal of the American Academy of Orthopaedic Surgeons during 2022. “The series will identify 12 comorbidities that the organization believes are disproportionately represented in vulnerable patient groups,” he said. “Our goal with these articles is to facilitate a transition from checklists to patient optimization.”
Wiznia is hoping to challenge other orthopaedic surgeons to reduce absolute cutoffs that prevent a patient from receiving total joint replacement. “While there may be instances where patients may never truly be safe for arthroplasty, there are many that can be brought along to a point to where they will be safe for surgery.”
“No matter the patient’s race, all patients are equally appropriate for total joint replacement.” Wiznia said. “Your race does not and should not dictate your eligibility for surgery.”
Article updated June 7, 2022.