Thursday, December 26, 2013

The effect of income, race and gender on outcome of joint arthroplasty. The 4Ps

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty

These authors sought evidence on the impact of socioeconomic factors on the outcome of total knee arthroplasty in patients under 60 years of age. As is the case for the post from December 20, this fits nicely with the concept that the outcome of any arthroplasty depends on the 4Ps: the problem, the patient, the procedure and the physician performing the surgery. While prior studies have focused primarily on surgical technique, implant details, and individual patient clinical factors, the focus here is on patient demographics and socioeconomic factors.

They surveyed 661 patients (average age, 54 years; range, 18–60 years; 61% female) 1 to 4 years after undergoing modern primary TKA for noninflammatory arthritis at five orthopaedic centers. Interestingly the data were collected by an independent third party with expertise in collecting healthcare data for state and federal agencies and blinded to all details regarding the patient and the care rendered. 

They found that patients reporting incomes of less than $25,000 were less likely to be satisfied with arthroplasty outcomes and more likely to have functional limitations after surgery than patients with higher incomes. Women were less likely to be satisfied and more likely to have functional limitations than men, and minority patients were more likely to have functional limitations than nonminority patients. The type of implant was not associated with outcomes after surgery. Household income was more important than minority status in predisposing to suboptimal results. After adjusting for socioeconomic factors, minority patients (Hispanic and black) reported inferior results on the functional outcome measures. 

They conclude that socioeconomic factors, in particular low income, are more strongly associated with satisfaction and functional outcomes in young patients after arthroplasty than demographic or implant factors. 

Since different clinical case series will have different mixes of diagnoses (the problem), patient factors (age, gender, overall health, socioeconomic factors, ethnicity, and insurance coverage), prostheses, and levels of physician experience, comparisons between studies will need to carefully control for these key variables.  It is also apparent that these factors may not be independent one of the others. Less healthy, less wealthy, more severely affected, patients may be more likely to receive care by less experienced surgeons, for example (N.B. this study only included high volume centers so that the effect of income, ethnicity, surgeon volume, etc may have been less than when 'all comers' are included).

The bottom line is that even though there is much marketing of the 'advantages' of one prosthesis over another, the problem, the patient and the physician are likely to be the more important of the "P"s in affecting the result of surgery.

The effect of race and income observed here has importance with respect to health care policy, access to health care, and profiling of hospitals and physicians with respect to the outcome of arthroplasty.


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