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Patients Who Have Limited English Proficiency Are More Likely to Receive Elective Total Joint Arthroplasty
John P M Angeles1, Maveric K I L Abella2, Anna G McGovern3
1Department of Orthopedic Surgery, Stanford University, Redwood City, California; Wright State University, Boonshoft School of Medicine, Dayton, Ohio.
Background:
Limited English proficiency (LEP) impedes access to equitable health care, particularly in elective surgical decision-making. We hypothesized that LEP would reduce the rate of receiving an elective total joint arthroplasty (TJA).
Methods:
We retrospectively reviewed patients diagnosed with hip or knee osteoarthritis from 2009 to 2018 (n = 4,922) under the care of fluent English proficiency (FEP) orthopaedic surgeons. Patients were categorized as LEP (n = 741, 15%) or FEP (n = 4,181, 85%) based on their self-reported primary language in the medical record. The primary outcome was an elective TJA within one year of the initial clinical encounter. Multivariable mixed-effects logistic regression, adjusting for demographic and clinical characteristics and the clustering of patients within surgeons, was used to assess differences in rates of TJA in patients who had LEP or FEP (α = 0.05).
Results:
The incidence of elective TJA was higher among LEP patients than FEP patients (46 versus 38%, P < 0.001). After adjusting for patient demographic and clinical factors, the odds for TJA remained 20% higher in LEP patients when compared to FEP patients (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.01 to 1.43, P < 0.001). A body mass index of 25.0 to 29.9, or 30.0 to 39.9 was also associated with nearly 20 to 45% higher odds of TJA (aOR: 1.22, CI: 1.03 to 1.44, P = 0.021 and aOR: 1.45, CI: 1.22 to 1.71, P < 0.001, respectively) when compared to a body mass index of 18.5 to 24.9. Age over 80 years also affected the odds of elective TJA (aOR: 0.67, CI: 0.49 to 0.91, P = 0.010).
Conclusions:
Having LEP was independently associated with higher odds of receiving an elective TJA. The association between LEP and the decision to undergo an elective TJA was present even after accounting for known surgical risk factors like obesity and age. Language proficiency likely plays a role in the shared decision-making between patients and surgeons.
Level Of Evidence:
Therapeutic Level III (retrospective case series).
