Keynote Address: The Need for Greater Racial and Ethnic Diversity in Orthopaedic Surgery

Background  

Advances in medicine in the past century have resulted in substantial reductions in morbidity and mortality in the United States. However, despite these improvements, ethnic and racial minorities continue to experience health status and healthcare disparities. There is inadequate national awareness of musculoskeletal health disparities, which results in greater chronic pain and disability for members of ethnic and racial minority groups. The Sullivan Commission concluded in 2004 the inability of the health professions to keep pace with the US population is a greater contributor to health disparities than lack of insurance.     

Surgery, Public Health, and Pakistan

Background  

Surgical healthcare is rapidly gaining recognition as a major public health issue. Surgical disparities are large, with poorest populations receiving the least amount of emergency and essential surgical care. In light of recent evidence, developing countries, such as Pakistan, must acknowledge surgical disease as a major public health issue and prioritize research and intervention accordingly.     

Defining Racial and Ethnic Disparities in THA and TKA

Background  

For minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.     

Few Insurance-Based Differences in Upper Extremity Elective Surgery Rates After Healthcare Reform

Background  

Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law’s enactment.     

Breakout Session: Ethnic and Gender Differences in Diabetic Foot Management and Amputations

Background  

Although the health status of all Americans has improved substantially in the past century, gender and ethnic disparities still persist. Gender and ethnic disparities in diabetic foot management and amputations are an important but largely ignored issue in musculoskeletal health care.     

Creating Musculoskeletal Programs for Culturally Diverse,Underserved Communities: a Community-Based Participatory Research Survey

Background

Arthritis and other musculoskeletal diseases are the most prevalent health conditions in the USA, causing enormous financial and social burdens, especially in underserved communities. Targeted care and prevention programs are urgently needed.

Questions/Purposes

Within an overall goal of revealing health disparities, the questionnaire explored (1) the use of and access to healthcare, (2) the factors affecting quality of life, and (3) the levels of provider–patient communication.

Methods

A New York City musculoskeletal hospital conducted a community health needs survey among its diverse ethnic/racial communities. A 39-item questionnaire was administered online, by mail, and in person (in English, Spanish, and Chinese). Answers were analyzed in terms of sociodemographics, to define health disparities within a total sample and two subsamples.

Results

In the total sample, respondents were 60% White, 16% Black, 14% Hispanic/Latino, and 11% Asian, mostly female, and aged 50 to 79. More than 17% of the total sample indicated they could not access a healthcare provider when needed. Poor nutrition and lack of physical activity were large areas of concern, as were falls and poor self-reported health status. Nearly all respondents said they took steps to communicate with their healthcare providers. Dramatic health disparities were found between Whites and non-Whites (e.g., non-Whites were most likely to rate their health poorly, consider their diet fair or poor, lack health insurance, and be unable to access a healthcare provider).

Conclusion

The findings are being used to further refine, develop, and expand the hospital’s community programs, especially for culturally diverse and underserved communities.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9413-9) contains supplementary material, which is available to authorized users.     

Socioeconomic Factors Impact Colon Cancer Outcomes in Diverse Patient Populations

Purpose  

Cancer disparities among racial and ethnic groups are major public health concerns. Our objective was to examine the impact of socioeconomic status (SES) on survival of colon cancer patients within major racial and ethnic groups.     

A critical review of racial/ethnic variables in osteoporosis and bone density research

Summary  

Racial and ethnic variables are common in research on variation in bone density. This literature review describes some of the common flaws associated with the use of these variables and provides some suggestions for how bone density research may be able to better document and address skeletal health disparities.     

Race and Health Disparities in Patient Refusal of Surgery for Early-Stage Non-Small Cell Lung Cancer: A SEER Cohort Study

Introduction  

Several factors, including race, age, stage, comorbid conditions, social support, and socioeconomic status, have been linked to the likelihood of a patient having surgery for early-stage non-small cell lung cancer (NSCLC). The aim of the present study is to determine the influence of race and health disparities on refusal of recommended potentially curative surgery.     

Travel of patients to distant hospitals for elective surgery in Japan: A cross-sectional analysis of a nationally representative sample

Purpose  

The principles and methods of the geographical allocation of healthcare resources and their relationships with patient behavior have long been issues in the health policy research of many countries. This study aimed to investigate the associations between specific healthcare services such as surgical procedures and the behavior of patients in selecting hospitals that may be related to health service allocations under the relatively deregulated social health insurance settings in Japan.     

Has Diversity Increased in Orthopaedic Residency Programs since 1995?

Background  

Diversity among health professionals is believed to be an important step toward improving patient communication and addressing health disparities. Orthopaedic surgery traditionally has been overly represented by Caucasian males, and it remains one of the least racially and gender-diversified surgical subspecialties. As the US population becomes increasingly diverse, a concomitant increase in ethnic diversity and gender diversity is needed to ensure that all Americans receive high-quality, culturally competent health care.     

Minimizing Disparities in Osteoporosis Care of Minorities With an Electronic Medical Record Care Plan

Background  

Ethnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.     

Gender and Race/Ethnicity Differences in Hip Fracture Incidence,Morbidity, Mortality,and Function

Background  

Hip fracture is an international public health problem. Worldwide, approximately 1.5 million hip fractures occur per year, with roughly 340,000 in the United States in individuals older than 65 years. In 2050, there will be an estimated 3.9 million fractures worldwide, with more than 700,000 in the United States. However, whether there are disparities in morbidity, mortality, and function between men and women or between races/ethnicities is unclear.     

Universal insurance and an equal access healthcare system eliminate disparities for Black patients after traumatic injury

Background

Although inequities in trauma care are reported widely, some groups have theorized that universal health insurance would decrease disparities in care for disadvantaged minorities after a traumatic injury. We sought to examine the presence of racial disparities in outcomes and healthcare utilization at 30- and 90-days after discharge in this universally insured, racially diverse, American population treated for traumatic injuries.

Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity in Uganda’s Public Hospitals

Background  

There are large disparities in access to surgical services due to a multitude of factors, including insufficient health human resources, infrastructure, medicines, equipment, financing, logistics, and information reporting. This study aimed to assess these important factors in Uganda’s government hospitals as part of a larger study examining surgical and anesthesia capacity in low-income countries in Africa.     

Potential disparities in trauma: the undocumented Latino immigrant

Background

Little is known about the quality of trauma care undocumented immigrants receive. Documentation status may serve as a risk factor for health disparities. We hypothesized that undocumented Latino immigrants have an increased risk of mortality after trauma compared with Latinos with legal residence.

Materials and methods

The medical records for Latino trauma patients at our university-based trauma center between 2007 and 2012 were retrospectively reviewed. Undocumented status was defined using two criteria: (1) lack of social security number and (2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Regression models were used to estimate the comparable risks of in-hospital mortality.

Results

Out of 2441 Latino trauma patients treated at our institution during the study period, 465 were undocumented. Latinos with legal residence and undocumented Latinos did not differ with regard to in-hospital mortality (3.4% versus 3.9%, respectively; P = 0.61). We found no association between documentation status and in-hospital mortality after trauma (odds ratio = 1.12 [0.43, 2.9]; P = 0.81). The independent predictors of in-hospital mortality included age, injury severity score, penetrating mechanism, and lack of private insurance but not documentation status.

Conclusions

Undocumented Latino immigrants did not have an increased risk of in-hospital mortality after trauma; however, being uninsured was associated with a higher risk of death after trauma. For Latinos, we found no disparities based on immigration status for mortality after trauma, though disparities based on insurance status continue to persist.     

Problems and needs for improving primary care of osteoarthritis patients: the views of patients, general practitioners and practice nurses

Background  

Osteoarthritis (OA) is highly prevalent and has substantial impact on quality of life as well as on healthcare costs. The general practitioner (GP) often is the first care provider for patients with this chronic disease. The aim of this study was to identify health care needs of patients with OA and to reveal possible obstacles for improvements in primary care management of OA patients.     

Effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to breast cancer genetic testing

BackgroundThere is an underuse of genetic testing in breast cancer patients with a lower level of education, limited health literacy or a migrant background. We aimed to study the effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to genetic testing.MethodsWe conducted a multicenter study in a quasi-experimental pre-post (intervention) design. The intervention consisted of an online module and a group training for surgical oncologists and specialized nurses in three regions in the Netherlands. Six months pre- and 12 months post intervention, clinical geneticists completed a checklist with socio-demographic characteristics including the level of health literacy of each referred patient. We conducted univariate and logistic regression analysis to evaluate the effect of the training program on disparities in referral to genetic testing.ResultsIn total, 3179 checklists were completed, of which 1695 were from hospital referrals. No significant differences were found in educational level, level of health literacy and migrant background of patients referred for genetic testing by healthcare professionals working in trained hospitals before (n = 795) and after (n = 409) the intervention. The mean age of patients referred by healthcare professionals from trained hospitals was significantly lower after the intervention (52.0 vs. 49.8, P = 0.003).ConclusionThe results of our study suggest that the health literacy training program did not decrease disparities in referral to genetic testing. Future research in a more controlled design is needed to better understand how socio-demographic factors influence referral to breast cancer genetic testing and what other factors might contribute.     

Racial disparity in an outreach pediatric surgical service

Aim

The aim of this study was to investigate whether racial disparities in healthcare exist within a New Zealand pediatric surgical outreach service in a high indigenous Māori population.

A perverse quality incentive in surgery: implications of reimbursing surgeons less for doing laparoscopic surgery

Background

Surgery is one of the highest priced services in health care, and complications from surgery can be serious and costly. Recently, advances in surgical techniques have allowed surgeons to perform many common operations using minimally invasive methods that result in fewer complications. Despite this, the rates of open surgery remain high across multiple surgical disciplines.

Methods

This is an expert commentary and review of the contemporary literature regarding minimally invasive surgery practices nationwide, the benefits of less invasive approaches, and how minimally invasive compared with open procedures are differentially reimbursed in the United States. We explore the incentive of the current surgeon reimbursement fee schedule and its potential implications.

Results

A surgeon’s preference to perform minimally invasive compared with open surgery remains highly variable in the U.S., even after adjustment for patient comorbidities and surgical complexity. Nationwide administrative claims data across several surgical disciplines demonstrates that minimally invasive surgery utilization in place of open surgery is associated with reduced adverse events and cost savings. Reducing surgical complications by increasing adoption of minimally invasive operations has significant cost implications for health care. However, current U.S. payment structures may perversely incentivize open surgery and financially reward physicians who do not necessarily embrace newer or best minimally invasive surgery practices.

Conclusions

Utilization of minimally invasive surgery varies considerably in the U.S., representing one of the greatest disparities in health care. Existing physician payment models must translate the growing body of research in surgical care into physician-level rewards for quality, including choice of operation. Promoting safe surgery should be an important component of a strong, value-based healthcare system. Resolving the potentially perverse incentives in paying for surgical approaches may help address disparities in surgical care, reduce the prevalent problem of variation, and help contain health care costs.