Massive TJA Study: Racial Bias Less at High Volume Hospitals

Do racial disparities change for total joint arthroplasty (TJA) patients depending on the volume of cases at their respective hospitals? A team of researchers tackled this question with a massive, nearly 2 million patient retrospective study and their findings are published in the July 2, 2021 edition of the Journal of Clinical Anesthesia under the title: “Disparities in the provision of regional anesthesia and analgesia in total joint arthroplasty: The role of patient and hospital level factors.”

Co-author Stavros G. Memtsoudis, M.D., Ph.D., M.B.A., attending anesthesiologist and director of Critical Care Services at Hospital for Special Surgery in New York explained the background for this study to OTW, “From our previous studies, we do know that disparities in anesthetic care amongst patients of different backgrounds exist. These disparities are especially problematic when they are associated with different outcomes such as when general vs. neuraxial anesthesia is being used or peripheral nerve blocks are or are not utilized. However, it is not clear if such disparities remain present in hospitals that perform high volumes of surgeries and thus are more likely to protocolize their care.”

The researchers retrospectively analyzed patients in the Premier Healthcare database who underwent elective total knee and hip arthroplasty (TKA/THA) from 2006 to 2019. They looked at use of neuraxial anesthesia and use of a peripheral block, using four separate models for each outcome and their association with white/non-white race.

“The first model examined the unadjusted relationship,” wrote the authors. “In the second model patient level characteristics (age, sex, payer, Deyo-Charlson comorbidity, and year of surgery) were added. In the third model, hospital-level characteristics (hospital location, teaching hospital, hospital size, and region) were added; while in the fourth model hospital-specific total joint arthroplasty volume was further added as a covariate; this was categorized into 3 categories (high, medium and low) based on the 1st and 3rd quartiles of average annual TKA/THA volumes.”

“Overall, 1,839,166 TKA and 983,580 THA surgeries were identified. In the TKA cohort, 19.0% and 17.1% of patients received neuraxial anesthesia and PNB, respectively; this was 16.9% and 8.9% for THA patients, respectively. Hospitals with a low total joint arthroplasty volume tended to serve a higher percentage of minority patients.”

“We did find that indeed for some orthopedic interventions disparities in anesthetic care disappeared or were reduced in hospitals with higher volumes,” commented Dr. Memtsoudis to OTW. “Our data suggest that hospitals performing high volumes of joint arthroplasties may have reduced disparities in anesthetic care. Although speculative, this may be due to the higher chance of care being protocolized rather than leaving best practices up to individual providers.”