Wednesday, August 26, 2015

Racial Disparities in Total Shoulder Arthroplasty - is it as simple as black and white?

Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes

These authors used the US Nationwide Inpatient Sample from 1998 to 2011 to compare utilization rates and time-trends in outcomes by race. They found that compared to Whites, Blacks had a lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83; p < 0.0001) and in 2011 (12.27 vs. 3.33; p < 0.0001).

Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years; p < 0.0001), more likely to be female (54.9 vs. 71.0 %; p < 0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0 % and 1.7 vs. 6.1 %; p < 0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %; p < 0.0001).  A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998–2000, 62 vs. 51.4 % (p = 0.02), and in 2009–2011, 34.4 vs. 27.3 % (p < 0.0001).

The authors concluded that "Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities."

Comment: The term 'racial disparity' may imply to some  an unjustified discrimination. The usual indications for total shoulder arthroplasty are quality of life-limiting symptoms attributable to glenohumeral arthritis in a person of sufficient health and longevity to have a good opportunity benefit from the procedure. It has been demonstrated that the rates of arthritis are different by race and lower in African Americans than Whites (see link); the rate of arthritis in Asian Americans is even lower. It is expected that the rates of arthroplasty would be lower in populations with lower rates of arthritis. The rates of glenohumeral arthritis in different racial groups has not been published to our knowledge.

In addition to the difference in rates of arthritis, the authors postulate that racial differences may be contributed to by barriers to health care access, lower socioeconomic status, lower health literacy and numeracy, poorer physician-patient communication, higher medication non-adherence, more risk averseness to therapies, lesser access to subspecialist surgeons that perform TSA, and perceptions of more risk and less benefit from arthroplasty. It is also apparent from the data presented in the paper that African American patients having TSA are more likely to have important co-morbidities and to have diagnoses other than osteoarthritis - both of which are associated with poorer outcomes from TSA.

So there are many factors that could influence the rate with which TSA is performed in individuals of different racial origin and before we "take action to reduce racial disparities" we should do a better job of identifying which factors account for these differences and whether these factors can be modified, rather than fixing the numbers by doing more total shoulders on individuals who are not good candidates. 

Our clinic is open to all patients, regardless of race, sex, age, or insurance. It is extremely rare for us to see an Asian American or an African American with glenohumeral arthritis. Interestingly enough, today we did see a 39 year old African American who had a good range of left shoulder motion and these x-rays showing early arthritis. He had not had a trial of therapy or medication for his arthritis. We did not offer him a total shoulder, but rather a gentle physical therapy and non-steroidal anti-inflammatory medication. Our management would have been the same if he had been White.

See a related discussion in a prior post.


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