JBJS Editor’s Choice—Racial Disparities Persist in Trauma Care

swiontkowski marc colorThe orthopaedic community has been aware of racial disparities in care delivery for two decades. The phenomenon has been most clearly elucidated in joint replacement surgery, but in the May 18, 2016 edition of The Journal, Dy et al. confirm that the issue is also at play in hip fracture care.

The authors analyzed the prospectively collected records of nearly 200,000 New York State residents who underwent hip fracture surgery between 1998 and 2010. After multivariable adjustment for factors such as patient characteristics and hospital/surgeon volume, Dy et al. found that black patients were at significantly greater risk for delayed surgery, a reoperation, readmission, and 1-year in-hospital mortality than white patients. The authors also found that patients covered by Medicaid (a marker for low socioeconomic status) were at increased risk for delayed hip-fracture surgery.

It is time for the orthopaedic community to develop an organized strategy to deal with this important social issue. Recruitment into the ranks of orthopaedists of underrepresented minorities, enhanced cultural-sensitivity training, and culturally relevant patient and family educational materials may begin to address the situation. Perhaps the AAOS, the AOA, and the J. Robert Gladden Orthopaedic Society could convene a meeting to develop such a strategic plan? I am confident we can begin to reduce racial and socioeconomic disparities if we put our collective minds to it.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

3 thoughts on “JBJS Editor’s Choice—Racial Disparities Persist in Trauma Care

  1. I agree that we need diversity in Orthopaedic surgery. I and my colleagues of other racial and ethnic backgrounds struggle equally with these cases.
    Will more diversity reduce the epidemic of obesity, DM, alcoholism, drug abuse, etc that plagues the groups that the Bone and Joint Journal politely refers to as experiencing Social Deprivation?

  2. Recruitment of a more diverse population of orthopaedic surgeons and orthopaedic traumatologists is a fine idea which does nothing to change the real source of the problem in the US: the wasteful maldistribution of healthcare here based upon income, race, and social status. This mirrors the large growth in income disparity in our country and is an equally serious issue.

    In 35 years of providing care for patients from poor and underserved social groups, I finally understand that excellent medical and surgical care for all of our population is a strategic national asset which can only be addressed by more rational and equable funding. The underlying forces of racial and cultural division will prolong the agony for years to come, until we arrive at the only real solution — Medicare for all of our citizens.

    A more diverse population of surgeons with second-rate resources and uninsured patients solves nothing. Neither does blaming the poor for being fat, drug-addled, and diabetic. And such afflictions show no racial categories in my office.

  3. Further research into health and healthcare disparities would be a great mistake until the scientific community learns how to measure those disparities. To date, virtually all health and healthcare disparities research has been fundamentally unsound as a result of failure to recognize patterns by which standard measures of differences between outcome rates tend to be systematically affected by the prevalence of an outcome. These patterns include the pattern whereby the rarer an outcome, the greater tends to be the relative differences in experiencing it and the smaller tends to be the relative difference in avoiding it. This means that, for example, as mortality declines, relative differences in mortality tend to increase while relative differences in survival tend to decrease; as healthcare improves, relative differences in receipt of appropriate care tend to decrease while relative differences in nonreceipt of care tend to increase.

    It also means that relative racial differences in adverse outcomes like mortality, poor health, and nonreceipt of healthcare tend to be larger, while relative differences in the corresponding favorable outcomes tend to be smaller, among populations and subpopulations where the adverse outcomes are comparatively uncommon (i.e., among persons who are well-educated or have high income or have health insurance, or among the populations of places like Minnesota and Massachusetts) than among populations and subpopulations where the adverse outcomes are comparatively common.

    Absolute differences and odds ratios also tend to be affected by the prevalence of an outcome though in a more complicated way than the two relative differences. Roughly, as outcomes go from being rare to being common, absolute differences tend to increase; as outcomes go from being common to being very common, absolute differences tends to decrease. As the prevalence of an outcome changes, the difference measured by the odds ratio tends to change in the opposite direction of the absolute difference.

    To date, no health and healthcare research has understood these patterns or endeavored to determine the extent to which observed changes in measure are functions of changes in the prevalence of the outcome, and the extent to which they reflect something meaningful about underlying processes and whether the forces causing outcome rates of advantaged and disadvantaged groups to differ have grown stronger or weaker over time.

    The first sentence of the underlying article by Dy et al. is exemplary of a near-universal misunderstanding in this area. It states: “Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes.” For decades researchers have been observing declines in mortality and increased relative differences in mortality and noting that the latter increases occurred “despite” the former declines. They have done so without understanding that increases in relative differences in mortality are to be expected “because of,” not “despite” general declines in mortality (and without recognizing that relative differences in survival have been declining).

    References 1 to 7 below explain these issues at length. See pages 36 to 40 of item 2 regarding the prevalence of the mistaken belief that reducing the frequency of an adverse outcome will tend to reduce relative differences in rates of experiencing it. Reference 8 explains the principal statistical issue (and the government’s failure to understand it) fairly succinctly.

    1. “The Mismeasure of Health Disparities,” Journal of Public Health Management and Practice (July/Aug. 2016)http://www.jpscanlan.com/images/The_Mismeasure_of_Health_Disparities_JPHMP_2016_.pdf
    2. Letter to American Statistical Association (Oct. 8, 2015)

    3. “The Mismeasure of Health Disparities in Massachusetts and Less Affluent Places,” Quantitative Methods Seminar, Department of Quantitative Health Sciences, University of Massachusetts Medical School (Nov. 18, 2015)
    Abstract: http://jpscanlan.com/images/UMMS_Abstract.pdf PowerPoint: http://jpscanlan.com/images/Univ_Mass_Medical_School_Seminar_Nov._18,_2015_.pdf

    4. “Race and Mortality Revisited,” Society (July/Aug. 2014)

    5. “Measuring Health and Healthcare Disparities,” Proceedings of Federal Committee on Statistical Methodology 2013 Research Conference. 2014 (March). http://jpscanlan.com/images/2013_Fed_Comm_on_Stat_Meth_paper.pdf

    6. “Can We Actually Measure Health Disparities?,” Chance (Spring 2006)

    7. “Race and Mortality,” Society (Jan./Feb. 2000)

    8. “Things government doesn’t know about racial disparities,” The Hill (Jan. 28, 2014).

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