CORRInsights®: Racial Disparities in Above-knee Amputations after TKA: A National Database Study

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In their retrospective analysis of National Inpatient Sample data from 2002 to 2011, George and colleagues found that even after adjusting for age and comorbidities such as septic and aseptic complications, black men had the highest risk of above-knee amputation (AKA) after TKA than any other group evaluated. The authors also found higher risks of AKA following knee arthroplasty for patients who were younger than 50 and older than 80 years of age. The current findings regarding disparities in AKA usage are consistent with other orthopaedic procedures shown to be associated with racial or gender disparities [11], including lower extremity arthroplasty [2, 12], total shoulder arthroplasty [13], cervical spine surgery [14], lumbar stenosis [8], and hip fractures [3].
AKA after a TKA is associated with short-term mortality (20% to 40%), as well as decreases in overall function and quality of life [4, 5]. The causes of racial disparities in healthcare procedures generally include quality of healthcare insurance, medical comorbidities, and support systems, both within the hospitalization and followup care [6, 7, 9-11, 16]. Could better preoperative, postoperative, and followup care decrease the overall complication rate? A recent analysis [6] of 7924 postdischarge patients who underwent lower extremity arthroplasty suggests the answer might be yes. That report found disparities based on both race and gender for discharge placement, with black patients going home directly from the hospital more frequently.
The use of quality measures as a means for reimbursing hospitals under Medicare [15] is one of the unintended consequences of racial disparities in orthopaedic procedures. In 2013, hospitals in Detroit, MI, USA had the highest mean penalties from Medicare when compared to other major Midwestern cities because of higher readmission rates for congestive heart failure, acute myocardial infarction, and pneumonia. Blacks comprise more than 80% of the city's population, the highest proportion of any major metropolitan city. Hospitals within the city will provide care for those who struggle economically and have difficulty with access to medical care. While the penalties by Medicare were meant to incentivize quality, they may in fact decrease the resources available for those treated in safety-net hospitals. For example, if the cuts limit the ability for a hospital to provide postdischarge planning services, it may exacerbate readmission rates.
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