This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (9)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Medical Practice  • Medical Practice, Other  • Surgery  • Surgical Interventions  • Orthopedic Surgery  • Prognosis/ Outcomes  • Alert me on articles by topic  Social Bookmarking   What's this?

Use of Hospitals With Worse Outcomes Following Total Knee Replacement by Patients From Vulnerable Populations

Elena Losina, PhD; Elizabeth A. Wright, PhD; Courtenay L. Kessler, BA; Jane A. Barrett, MSc; Anne H. Fossel; Alisha H. Creel, BA; Nizar N. Mahomed, MD, ScD; John A. Baron, MD, MPH; Jeffrey N. Katz, MD, MS

Arch Intern Med. 2007;167(2):182-186.

Background  Neighborhood sociodemographic characteristics are associated with health care utilization across many conditions. There has been little study of whether total knee replacement (TKR) recipients from vulnerable populations, including racial and ethnic minorities, the poor, the elderly, and the less well educated, are more likely to use low-volume hospitals (LVHs).

Methods  We used Medicare claims and census data to identify a national cohort of Medicare beneficiaries who had elective TKR. We defined an LVH as a center performing fewer than 26 TKRs per year, and we used geocoding to identify "bypassers" (patients who had a high-volume hospital closer to their residence than the one where they had TKR). We used multivariate logistic regression to examine the association of patient and neighborhood characteristics with utilization of LVHs and bypassing. We derived a summative measure of neighborhood vulnerability that included 4 high-risk characteristics (factors were high proportions of residents who are minority individuals, who have foreign-born status, with low income, and with low education).

Results  Of 113 015 TKR recipients, 13 120 (11.6%) used LVHs. Of all the TKR recipients, 9815 (8.7%) bypassed a center with a higher TKR volume than the one they used. Multivariate analyses showed that nonwhite (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.16-1.33), poor (OR, 1.94; 95% CI, 1.83-2.08), and nonurban (OR, 1.94; 95% CI, 1.87-2.01) subjects were more likely to use LVHs. The TKR recipients from neighborhoods with 3 or 4 vulnerability factors were more likely than patients in neighborhoods with no vulnerability factors to use an LVH and bypass a high-volume hospital.

Conclusion  Efforts to inform patients about the association of volume with TKR outcomes should target rural areas and vulnerable populations in urban settings.

Author Affiliations: Department of Biostatistics, Boston University School of Public Health, Boston, Mass (Dr Losina); Section of Clinical Sciences (Drs Losina, Wright, and Katz and Mss Kessler, Fossel, and Creel), Division of Rheumatology, Immunology and Allergy, and Departments of Medicine and Orthopaedic Surgery (Dr Katz), Brigham and Women's Hospital, Boston; Departments of Environmental Health and Health Policy and Management, Harvard School of Public Health, Boston (Drs Wright and Katz); Departments of Medicine (Dr Baron) and Community Medicine (Ms Barrett and Dr Baron), Dartmouth Medical School, Hanover, NH; and the Musculoskeletal Health and Arthritis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario (Dr Mahomed).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Racial Disparities in Total Knee Replacement Among Medicare Enrollees--United States, 2000-2006
JAMA 2009;302:1525-1526.
FULL TEXT  

The Need for Increased Access to the U.S. Health-Care System
Bible et al.
JBJS 2009;91:476-484.
FULL TEXT