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Disparities in the utilization of high-volume hospitals for total knee replacement
Nelson F SooHoo1, David S Zingmond, Clifford Y Ko
1Department of Orthopaedic Surgery, UCLA, Los Angeles, CA 90095, USA. nsoohoo@mednet.ucla.edu
Insights
Patients from minority racial/ethnic groups and those with Medicaid insurance were more likely to receive total knee replacement at lower-volume hospitals. This highlights disparities in care quality for these populations.
Area of Science:
- Orthopedic Surgery
- Health Services Research
- Health Disparities
Background:
- Higher surgical volumes in hospitals correlate with better outcomes for total knee replacement (TKR).
- Understanding patient demographics at high-volume vs. low-volume TKR centers is crucial for equitable care.
Purpose of the Study:
- To identify patient characteristics associated with undergoing TKR at high-volume hospitals.
- To compare patients receiving TKR at high-volume versus low-volume centers.
Main Methods:
- Analysis of 222,684 TKR discharge records in California (1991-2001).
- Hospitals categorized into low, intermediate, and high surgical volume tiers.
- Logistic regression models used to assess the relationship between race/ethnicity, insurance, and hospital volume, controlling for age, gender, and comorbidity.
Main Results:
- Non-Caucasian patients (Black, Hispanic, Asian/Pacific Islander) had a significantly higher risk of TKR at low-volume hospitals.
- Medicaid insurance was an independent predictor of receiving care at low-volume centers.
- Age and comorbidity were not significant predictors of TKR location based on hospital volume.
Conclusions:
- Significant disparities exist in patient populations treated at high-volume TKR hospitals.
- Racial/ethnic minority status and Medicaid insurance predict utilization of low-volume TKR facilities.
- Addressing racial and socioeconomic disparities is essential for improving TKR quality at lower-volume centers.
Objective:
Higher hospital surgical volumes have been associated with lower complication rates following total knee replacement. The objective of this study is to identify the characteristics of patients who undergo total knee replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals.
Methods:
Discharge data from patients undergoing total knee replacement in California from 1991-2001 were analyzed. Hospitals were classified into three tiers of low, intermediate or high surgical volume. The relationship between race/ethnicity and insurance status and the utilization of low-volume and high-volume hospitals were examined by creating separate logistic regression models that corrected for covariates, including age, gender and comorbidity.
Results:
This study analyzed 222,684 primary total knee replacements during the study period. Patients of non-Caucasian race/ethnicity had higher relative risk ratios for being treated at a low-volume center, including black patients [relative risk ratio (RRR) = 1.73, 95% confidence Interval (CI): 1.09-2.76, p = 0.02]; Hispanic patients (RRR = 3.13, 95% CI: 2.31-4.23, p < 0.001) and Asian/Pacific Islanders (RRR = 2.95, 95% CI: 1.89-4.62, p < 0.001). Medicaid insurance was also an independent predictor of treatment at low-volume hospitals. Age and comorbidity were not statistically significant predictors for receiving care at low-volume centers.
Conclusions:
There are substantial disparities in the characteristics of patients receiving care at hospitals performing a high volume of total knee replacements. Black, Hispanic and Asian race/ethnicity as well as Medicaid insurance were predictors of utilization of a low-volume hospital. This study supports the need to consider racial and socioeconomic disparities in efforts to improve the quality of care of patients undergoing total knee replacement at lower-volume hospitals.
