Most health researchers attribute the well-defined racial disparities seen in outcomes for both acute and chronic illnesses to unequal access to health care, particularly preventive care. There are currently between 30 million and 40 million uninsured patients in the US who do not have access to routine preventive care and receive the majority of their health care through hospital emergency rooms. This seems to be related to the prevailing opinion in our country that access to primary care physicians and routine preventive measures is not a basic right.
Emergency care, however, is more or less available to everyone, and that would theoretically reduce or eliminate the racial disparities in outcomes for emergent conditions such as hip fractures. Yet, in 2016, JBJS published research indicating that disparities in care and outcome occur in the management of hip fracture, with black patients found to be at greater risk for delayed surgery, reoperation, readmission, and 1-year mortality than white patients. That begs the question whether there are inherent racial differences beyond the health-care delivery system that might partly account for these disparate outcomes.
In the July 5, 2018 issue of The Journal, Okike et al. try to answer that question. The authors used data from Kaiser Permanente, a large health system with a modestly diverse population that has equal access to care that is known for its adherence to standardized protocols. Okike et al. analyzed the outcomes of nearly 18,000 hip fracture patients according to race (black, white, Hispanic, and Asian). In this uniformly insured population with few or no barriers to access, Okike et al. found that the outcomes for patients, regardless of race, were similar. These findings strongly suggest that when patients are given equal access to health care that is delivered according to standardized protocols, the racial disparities found in previous studies of outcomes of emergent conditions may disappear.
Okike et al. are quick to emphasize that their findings are not an indication that “efforts to combat disparities are no longer required.” I would argue that this study further supports the need to address the issue of access to care on a policy level if we are going to make progress toward achieving racial equality in medical and orthopaedic outcomes. Much of the access-to-care progress we made between 2008 and 2016 is evaporating; I look forward to the day when we can redirect the national focus on this issue at the highest policy-making levels.
Marc Swiontkowski, MD