African American patients more likely to receive replacement surgery in low-quality hospitals

Study reveals evidence of racial disparities in access to hospitals that perform high-quality joint replacement care

Racial minorities have reduced access to high-quality joint replacement care, according to Dr. Xueya Cai and colleagues from the University of Iowa in the US. Their work, published online in Springer's journal Clinical Orthopaedics and Related Research, shows that African American patients are more likely than Caucasians to receive total knee arthroplasty (or replacement surgery) in low-quality hospitals.

Total joint arthroplasty is widely performed in patients of all races with severe osteoarthritis to relieve pain and improve joint function and mobility. Although several studies have suggested that racial minority patients are less likely to undergo joint replacement surgery, little is known about the quality of arthroplasty care that African Americans receive as compared to Caucasians.

Using data from the Medicare Provider Analysis and Review (MedPAR) files between 2002 and 2005, which contain information regarding hospitalization for Medicare beneficiaries, Cai and colleagues profiled US hospitals' quality of care. Quality was based on the rate of complications including sepsis, hemorrhage, pulmonary embolism, deep vein thrombosis and severe wound infection, as well as the number of deaths, experienced in the 90 days after total knee replacement surgery.

To test for a racial difference in access to high-, intermediate- and low-quality hospitals, the authors then looked at 91,599 elderly patient admissions for total knee replacement between July and December 2005 in 2,842 hospitals.

Their analyses, which focused on Caucasian and African American patients only, showed that African American patients undergoing total knee arthroplasty were less likely to be admitted to high-volume hospitals. Instead, compared to Caucasian patients, they were more likely to be admitted to hospitals that perform fewer knee replacements, which have been correlated to lower-quality knee arthoplasty surgery. The fact that African American race was a predictor for admissions to low-quality hospitals, provides direct evidence of racial disparities in access to high-quality arthroplasty care.

Dr. Xueya Cai concludes: "This racial disparity in access to high-quality arthroplasty care is a major issue, especially as arthroplasties continue to be more widely performed in both Caucasian and non-Caucasian patients with severe osteoarthritis. More work is needed to explore African American neighborhoods, as well as social and physician-referring factors to better understand and address the issues of unequal access and quality of arthroplasties."