Are African American patients more likely to receive a total knee arthroplasty in a low-quality hospital?

BACKGROUND: Total joint arthroplasty is widely performed in patients of all races with severe osteoarthritis. Prior studies have reported that African American patients tend to receive total joint arthroplasties in low-volume hospitals compared with Caucasian patients, suggesting potential racial disparity in the quality of arthroplasty care. QUESTIONS/PURPOSES: We asked whether (1) a hospital outcome measure of risk-adjusted mortality or complication rate within 90 days of primary TKA can be directly used to profile hospital quality of care, and (2) African Americans were more likely to receive TKAs at low-quality hospitals (or hospitals with higher risk-adjusted outcome rate) compared with Caucasian patients. PATIENTS AND METHODS: We developed a risk-adjusted, 90-day postoperative outcome measure to identify high-, intermediate-, and low-quality hospitals based on patient records in the Medicare Provider Analysis and Review files between July 1, 2002, and June 30, 2005 (the first cohort). We then analyzed a second cohort of African American and Caucasian patients receiving Medicare who underwent primary TKAs between July and December 2005 to determine the independent impact of race on admissions to high-, intermediate-, and low-quality hospitals.
RESULTS: The risk-adjusted postoperative mortality/complication rate varied substantially across hospitals; hospitals can be meaningfully categorized into quality groups. In the second cohort of admissions, 8% of African American patients (n = 4894) versus 9.2% of Caucasian patients (n = 86,705) were treated in high-quality hospitals whereas 14.7% of African American patients versus 12.7% of Caucasians patients were treated in low-quality hospitals. After controlling for patient demographic, socioeconomic, geographic, and diagnostic characteristics, the odds ratio for admission to low-quality hospitals was 1.28 for African American patients compared with Caucasian patients (95% CI, 1.18-1.41).
CONCLUSIONS: Among elderly Medicare beneficiaries undergoing TKA, African American patients were more likely than Caucasian patients to be admitted to hospitals with higher risk-adjusted postoperative rates of complications or mortality. Future work is needed to address the residential, social, and referring factors that underlie this disparity and implications for outcomes of care.