Patients who live in socially or economically vulnerable neighborhoods are more likely to use low-volume hospitals for total knee replacement surgery, and even bypass a closer, high-volume hospital to do so. That is the conclusion of a nationwide study led by Jeffrey N. Katz, an HMS associate professor of medicine and of orthopedic surgery at Brigham and Women’s Hospital and an HSPH associate professor in the Departments of Environmental Health and of Health Policy and Management, and Elena Losina, HMS visiting associate professor of orthopedic surgery at BWH. Their paper appears in the Jan. 22 Archives of Internal Medicine.
“The findings speak to the potential disparities in health care because not only are patients from vulnerable populations less likely to use these types of procedure, but those who do utilize them end up in centers with potentially worse outcomes,” said Losina, the lead author on the paper.
It is well accepted that for surgeries such as total knee replacement, higher volume hospitals have better outcomes, but it is not clear whether that message is getting across to the general population, particularly minorities and those with low incomes or low levels of education. The study suggests that it is not.
Losina and colleagues used nationwide Medicare claims data to identify more than 100,000 people who had elective total knee replacement surgery and then correlated their neighborhood status with hospital use. The researchers found that those who were from neighborhoods with one, two, or three of the four defined vulnerability factors (a high proportion of minority, foreign-born, low-income, or low-education residents) were 1.3, 1.5, and 2.0 times more likely to use a low-volume hospital. If patients came from urban neighborhoods where more than 25 percent of the population is below the poverty line and more than 50 percent are minorities, they were twice as likely to bypass a high-volume hospital.
Given the aging population and the increasing incidence of arthritis, the data are troubling. “There is concern that in more vulnerable neighborhoods, poor outcomes relayed by word-of-mouth could deter patients from total knee replacements, which are more than 90 percent successful, dramatically increasing mobility and improving quality of life in the elderly,” said Losina.
