Are the eligibility criteria used for hip and knee replacements color, income or sex blind?
Perhaps not, says new work from Johns Hopkins. The study, “Eligibility Criteria for Lower Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities,” appeared in the November 14, 2018 edition of Clinical Orthopaedics and Related Research.
Co-author Casey Humbyrd, M.D., assistant professor of orthopedic surgery at the Johns Hopkins University School of Medicine, explained to OTW why she became interested in this question, “I became interested in this work as I noticed a shift from the time when I began residency to practice in how patients with medical comorbidities were approached by their surgeons.”
“While I think the focus on preoperative surgical optimization is excellent, there also seemed to be a trend where certain patients could no longer access surgeons, due to their medical issues. As an ethicist, I became concerned about potential justice implications, given the uneven distribution of health within our population.”
“Based on publicized cutoffs in the arthroplasty literature, and driven by new payment models in arthroplasty, I wanted to investigate potential population impacts—with respect to whom receives care—if broad cutoffs were used.”
Humbyrd and her team collected information from 21,294 adults over the age of 50 and found that those who met cutoff factors tended to have higher incomes, more education and be white.”
“For example, said the researchers, “using the cutoff of allowing only those with a BMI [body mass index] under 35 to have surgery resulted in African-Americans being denied 38% more often than whites. Overall, women were 39% less likely to be eligible than men. People with household incomes less than $45,000 were 19% less likely to receive surgery than people with higher income… When using the 8% cutoff for hemoglobin A1C, African-Americans and Hispanics were half as likely to be eligible for the surgeries as white people.”
Dr. Humbyrd told OTW, “I think the most important findings relate to the potential implications for worsening disparities if a cutoff system for medical comorbidities is blindly followed. In all the areas evaluated—body mass index, diabetic control and smoking—those groups with worse health would have even less access to medical care. If cutoffs are blindly followed, physicians will worsen existing health disparities, including in the receipt of hip and knee replacement.”
“First, I think it is important for orthopedic surgeons to understand health disparities and how we can work to decrease rather than worsen these disparities. Second, I hope surgeons who are using cutoffs will consider whether an optimization approach may be better for the patient. For example, weight reduction rather than a strict BMI requirement. Or tobacco reduction rather than cessation. I would never advocate that a surgeon must operate regardless of comorbidities, rather, I think the goal is partnership with the patient to achieve the best health outcome.”
“As orthopedic surgeons, we may be less likely to consider our impact on public health and health disparities, in the same way that a primary care physician might be. We aren’t doing the routine health maintenance and preventative medicine that leads to significant mortality differences based on race and income. Yet, we do have an incredible public health role, given the quality of life benefits offered by orthopedic surgeons to their patients.”
