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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Relationship of low income to surgical outcome

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty.

In past posts we discussed the "4Ps" that influence the result of surgery: the Problem (e.g. arthritis or massive cuff tear) , the Patient with the problem (e.g. age, gender, smoking, socioeconomic factors) , the Procedure to be performed (e.g. hemiarthroplasty, reverse total shoulder) and the Physician performing the procedure (e.g. extent of training, annual volume of similar cases).

This article focuses on the second P, socioeconomic factors and their relationship to the results of total knee replacement in young patients. The authors surveyed 661 patients 1 to 4 years after primary TKA for noninflammatory arthritis. While this study concerns total knees, its findings are likely to hold true for elective surgery as well.

They found that patients reporting incomes of less than $25,000 were less likely to be satisfied with  outcomes and more likely to have functional limitations than patients with higher incomes. At a lower level of association, women and minority patients were more likely to have functional limitations. Employment status and educational level at the least impact on satisfaction and function. The choice of implant did not have a significant effect on the outcome of surgery.

While much of our literature focuses on the type of procedure and the choice of implant, this study clearly demonstrates that the second P - the patient - has a strong influence on the result. Or as Osler said, "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has."

The reasons behind the association of low income with poorer outcome are as yet unknown. Readers may wish to visit a recent post regarding the relationship between revision and type of insurance. 

In an age of 'pay for performance', it will be essential that the incentives placed on good performance do not create an incentive to inappropriately avoid treating patients with lower incomes or those on Medicare and Medicaid.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


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