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Racial Disparities in Arthroscopic Rotator Cuff Repair: An Analysis of Utilization and Perioperative Outcomes

Open AccessPublished:September 23, 2022DOI:https://doi.org/10.1016/j.jseint.2022.09.002

      ABSTRACT:

      Background

      There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures.

      Methods

      The American College of Surgeons National Surgical Quality Improvement Program database was utilized to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 – 2019. Baseline demographics, utilization trends, and perioperative measures including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission were analyzed.

      Results

      Of 42,443 included patients, 38,090 (89.7%) were White and 4,353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). Additionally, logistic regression showed that Black or African American patients had increased odds of longer operative time [adjusted rate ratio (ARR) 1.07, 95% confidence interval (CI) 1.05-1.08] and time from operation to discharge [ARR 1.19, 95% CI 1.04-1.37]. Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared to White patients (ptrend < .0001).

      Conclusion

      Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address causes of these inequalities to provide equitable care.

      Keywords

      Healthcare in the United States, like many other facets of modern society, is disproportionately affected by differences in race, ethnicity, sex, and socioeconomic status. For example, when analyzing racial identity, Black or African American patients are more likely to have hypertension, diabetes mellitus, and coronary artery disease (CAD) compared to White patients.
      • Reinier K.
      • Rusinaru C.
      • Chugh S.S.
      Race, ethnicity, and the risk of sudden death.
      Specifically in orthopedics, differences in utilization rates based on patients’ race have been observed in total joint arthroplasty.,7,27 Pandya et al demonstrated a lower rate of total knee arthroplasties among minority patients, along with a lower rate of total shoulder arthroplasties among Black males.
      • Pandya N.K.
      • Wustrack R.
      • Metz L.
      • Ward D.
      Current Concepts in Orthopaedic Care Disparities.
      As such, various government and orthopedic organizations, such as the American Academy of Orthopedic Surgery, Association of Bone and Joint Surgery, Orthopaedic Research Society, and the Department of Health and Human Services, have created initiatives to address racial disparities in orthopedic care.
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      • Graham G.
      • Glied S.A.
      Reducing Racial And Ethnic Disparities: The Action Plan From The Department Of Health And Human Services.
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      • O’Connor M.I.
      • Lavernia C.J.
      • Nelson C.L.
      AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium: Editorial Comment: A Call to Arms: Eliminating Musculoskeletal Healthcare Disparities.
      However, according to Amen et al and Best et al, the results have shown that disparities continue to exist between Black and White patients regarding utilization, length of stay, and perioperative complication rates in total joint arthroplasty.
      • Amen T.B.
      • Varady N.H.
      • Rajaee S.
      • Chen A.F.
      Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.
      ,
      • Best M.J.
      • Aziz K.T.
      • McFarland E.G.
      • Martin S.D.
      • Rue J.P.H.
      • Srikumaran U.
      Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States.
      ,
      • Best M.J.
      • McFarland E.G.
      • Thakkar S.C.
      • Srikumaran U.
      Racial Disparities in the Use of Surgical Procedures in the US.
      Specifically, Black patients tend to have increased lengths of stay, risk of mortality, and risk of complications during both total hip arthroplasty and total knee arthroplasty. While prior research has provided valuable insight into the inequality that exists in orthopedics in North America, there continues to be a paucity of literature specifically addressing the impact of racial disparities on utilization and perioperative measures in arthroscopic rotator cuff repair despite its increase in demand.
      Therefore, the primary purpose of this study is to investigate racial disparities amongst patients undergoing arthroscopic rotator cuff repair procedures by analyzing perioperative measures and trends over an extended timeframe. It is essential for clinicians to understand underlying prognostic factors, as well as any other barriers patients must overcome, to provide equitable care at an individual level. We hypothesize that there will be statistically significant differences in the complication rates between White and Black or African American patients.

      MATERIALS AND METHODS

      Source Data

      This study utilized data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2019. The NSQIP registry serves to provide 30-day postoperative complication data that is collected and stored with the end goal of decreasing the frequency of adverse events and complications.
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      Use of the National Surgical Quality Improvement Program in Orthopaedic Surgery.
      The database exhibits a high-quality collection method and undergoes continuous rigorous audits in order to maintain its validity and accuracy.
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      • Singh K.
      • Grauer J.N.
      Nationwide Databases in Orthopaedic Surgery Research.
      The database contains over 300 perioperative variables from over 700 medical institutions within the United States.
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      • Singh K.
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      The NSQIP: A new frontier in surgery.
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      • Blumer A.
      • Obremskey W.T.
      • Sethi M.K.
      Use of the National Surgical Quality Improvement Program in Orthopaedic Surgery.
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      • Hallstrom B.R.
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      Prioritizing Perioperative Quality Improvement in Orthopaedic Surgery.
      Importantly, it has been used in previous orthopedic studies to articulate differences in surgical procedures.
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      • Best M.J.
      • Martin S.D.
      Comparison of perioperative complications following surgical treatment of shoulder instability.
      ,
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      • Eberlin C.T.
      • et al.
      Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures.
      Institutional review board approval was obtained for this study (#2021P001230).

      Inclusion Criteria

      Patients included in this study were adults (age ≥18) found in the NSQIP database who underwent an arthroscopic rotator cuff repair procedure according to the Current Procedural Terminology (CPT) code 29827. Baseline demographics included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) status, race, smoking status, diabetes mellitus, severe chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), steroid use for chronic condition, and hypertension requiring medication. Total operative time, total length of hospital stay, days from operation to discharge, and readmission were also analyzed. Similar to previous studies utilizing the NSQIP database, adverse events were classified as serious or minor.
      • Bokshan S.L.
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      • Owens B.D.
      Comparison of 30-Day Morbidity and Mortality After Arthroscopic Bankart, Open Bankart, and Latarjet-Bristow Procedures: A Review of 2864 Cases.
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      • Kucharik M.P.
      • Naessig S.A.
      • Best M.J.
      • Martin S.D.
      Comparison of perioperative complications following surgical treatment of shoulder instability.
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      • Goodloe J.B.
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      • Slone H.S.
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      • Best M.J.
      • Rudisill S.S.
      • Naessig S.A.
      • Eberlin C.T.
      • et al.
      Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures.
      Serious adverse events included: death, reoperation, pulmonary complications (unplanned intubation or ventilator greater than 48 hours), pneumonia, cardiac complications (cardiac arrest or myocardial infarction), renal complications (progressive renal insufficiency or acute renal failure), thromboembolic complications (DVT/thrombophlebitis or pulmonary embolism), deep wound complications (deep incisional surgical site infection, wound dehiscence, or joint space infection), and sepsis. Minor adverse events included superficial surgical site infection and urinary tract infection. Furthermore, trends for serious adverse events, length of total hospital stay, and relative procedure rates over the study length were examined.

      Statistical Analysis

      Statistical analyses were performed using SAS v9.4 (SAS Institute Inc., Cary, NC, USA). Baseline demographic variables as well as outcome variables were analyzed using either chi-squared tests or Fisher’s exact tests. Binomial models and logistic regression models were employed for continuous and categorical variables, respectively. Cochran-Armitage Trend test was utilized in order to discern any significance in relative procedural usage over the study period. Continuous variables are reported as mean ± standard deviation. P-values <0.05 were considered significant.

      RESULTS

      A total of 42,443 patients were included in this analysis. There were 38,090 (89.7%) White patients and 4,353 (10.3%) Black or African American patients. Significant differences between the two patient groups were observed regarding age, sex, BMI, diabetes mellitus, ASA class, smoking status, congestive heart failure, and hypertension requiring medication, (p<0.001 for all). White patients tended to be older [90.8% vs. 85.2% (> 45 years), p<0.001] with a higher percentage being males (58.8% vs. 47.6%, p<0.001). There was a larger proportion of Black or African American patients that were classified as overweight or obese compared to White patients (89.9% vs. 83.8%, p<0.001). Regarding medical comorbidities, the Black or African American cohort had a larger proportion of patients with diabetes mellitus (23.6% vs. 15.6%), smoking within the past year (16.9% vs. 14.8%), CHF (0.3% vs. 0.1%), and hypertension requiring medication (59.2% vs. 45.9%), (p<0.001 for all). A comprehensive summary of baseline demographics and clinical characteristics are presented in Table 1.
      Table 1Clinical and demographic characteristics of Black or African American and White patients undergoing arthroscopic rotator cuff repair
      VariablesTotal N=42443(%)Black or African American N=4353(%)White N=38090(%)P Value
      Age Group<.001
      Statistically significant (α = 0.05)
      Chi-square test
       0-24203 (0.5)29 (0.7)174 (0.5)
       25-34719 (1.7)106 (2.4)613 (1.6)
       35-443223 (7.6)508 (11.7)2715 (7.1)
       45
      Exact test
      38297 (90.2)3710 (85.2)34587 (90.8)
      Sex<.001
      Statistically significant (α = 0.05)
      Chi-square test
       Female17960 (42.3)2280 (52.4)15680 (41.2)
       Male24483 (57.7)2073 (47.6)22410 (58.8)
      BMI Group<.001
      Statistically significant (α = 0.05)
      Chi-square test
       Normal (<24.9 kg/m2)6559 (15.6)435 (10.0)6124 (16.2)
       Overweight (25-29.9 kg/m2)14706 (34.9)1305 (30.1)13401 (35.4)
       Obese (>30 kg/m2)20910 (49.6)2592 (59.8)18318 (48.4)
      Diabetes Mellitus6982 (16.5)1026 (23.6)5956 (15.6)<.001
      Statistically significant (α = 0.05)
      Chi-square test
      ASA Class<.001
      Statistically significant (α = 0.05)
      Chi-square test
       13269 (7.7)299 (6.9)2970 (7.8)
       224310 (57.3)2350 (54.0)21960 (57.7)
       3
      Exact test
      14844 (35.0)1704 (39.1)13140 (34.5)
      Current Smoker (within one year)6361 (15.0)735 (16.9)5626 (14.8)<.001
      Statistically significant (α = 0.05)
      Chi-square test
      Severe COPD1384 (3.3)124 (2.8)1260 (3.3)0.106
      Chi-square test
      Congestive Heart Failure61 (0.1)15 (0.3)46 (0.1)<.001
      Statistically significant (α = 0.05)
      Chi-square test
      Hypertension Requiring Medication20051 (47.2)2579 (59.2)17472 (45.9)<.001
      Statistically significant (α = 0.05)
      Chi-square test
      Steroid Use (Chronic Condition)876 (2.1)104 (2.4)772 (2.0)0.111
      Chi-square test
      Abbreviations: BMI: Body Mass Index; ASA: American Society of Anesthesiologist
      Statistically significant (α = 0.05)
      + Exact test
      C Chi-square test

      Perioperative Metrics of Arthroscopic Rotator Cuff Repair

      Importantly, there were no significant differences between Black or African American and White patients when comparing length of total hospital stay, readmission, serious adverse events, and minor adverse events. However, statistically significant differences were noted between the two cohorts with regards to total operative time and days from operation to discharge. Black or African American patients had a longer mean operative time [94.0 ± 45.7 vs. 88.9 ± 45.9 minutes] and mean time from operation to discharge from the hospital [0.17 ± 2.1 vs. 0.13 ± 1.3 days] when compared to White patients, (p<0.001 for both) (Table 2).
      Table 2Comparison of outcomes between Black or African American and White patients following arthroscopic rotator cuff repair
      Total N=42443(%)Black or African American N=4353(%)White N=38090(%)P Value
      Total Operative Time (Mean ± SD)89.5 ± 45.994.0 ± 45.788.9 ± 45.9<.001
      Statistically significant (α = 0.05)
      Negative binomial model
      Length of Total Hospital Stay (Mean ± SD)0.16 ± 2.40.17 ± 2.10.16 ± 2.50.408
      Negative binomial model
      Days from Operation to Discharge (Mean ± SD)0.1 ± 1.40.17 ± 2.10.13 ± 1.3<.001
      Statistically significant (α = 0.05)
      Negative binomial model
      Any Readmission437 (1.07)50 (1.19)387 (1.05)0.417
      Chi-square test;
      Serious Adverse Events353 (0.83)35 (0.80)318 (0.83)0.832
      Chi-square test;
       Death10 (0.02)1 (0.02)9 (0.02)1
      Fisher’s exact test;
      Exact test
       Return to OR118 (0.28)9 (0.21)109 (0.29)0.346
      Chi-square test;
       Pulmonary Complications28 (0.07)5 (0.11)23 (0.06)0.202
      Fisher’s exact test;
      Exact test
       Cardiac Complications31 (0.07)4 (0.09)27 (0.07)0.554
      Fisher’s exact test;
      Exact test
       Renal Complications8 (0.02)0 (0.00)8 (0.02)1
      Fisher’s exact test;
      Exact test
       Thromboembolic Complications123 (0.29)14 (0.32)109 (0.29)0.680
      Chi-square test;
       Deep Wound Complications32 (0.08)3 (0.07)29 (0.08)1
      Fisher’s exact test;
      Exact test
      Minor Adverse Events134 (0.32)13 (0.30)121 (0.32)0.832
      Chi-square test;
       Superficial surgical site infection50 (0.12)3 (0.07)47 (0.12)0.321
      Chi-square test;
       Urinary Tract Infection84 (0.20)10 (0.23)74 (0.19)0.618
      Chi-square test;
      Statistically significant (α = 0.05)
      + Exact test
      C Chi-square test;
      F Fisher’s exact test;
      NB Negative binomial model
      In order to further evaluate the differences in outcomes between Black or African American and White patients, a logistic regression analysis was performed while controlling for age, sex, BMI, diabetes mellitus, ASA class, smoking status, congestive heart failure, and hypertension (Table 3). Compared to White patients, Black or African American patients had an increased risk of experiencing longer total operative time [adjusted relative risk (ARR): 1.07, 95% confidence interval (CI) 1.05-1.08, p<0.001] as well as a longer elapsed time from operation to time of discharge [RR: 1.19, 95% CI 1.04-1.37, p=0.013].
      Table 3Adjusted analysis comparing perioperative and postoperative metrics between Black or African American and White patients following arthroscopic rotator cuff repair
      OutcomesAdjusted ORa/Adjusted RRb95% CIP value
      Readmission1.03a0.761.400.8274
      SAE0.96a0.681.370.8329
      MAE0.84a0.481.470.5496
      Total Operative Time1.07b1.051.08<.0001
      Statistically significant (α = 0.05)
      Length of Total Hospital Stay1.03b0.881.190.7290
      Days from Operation to Discharge1.19b1.041.370.0130
      Statistically significant (α = 0.05)
      All values computed relative to white patients
      All values adjusted for age, sex, BMI, diabetes mellitus, ASA class, smoking status, CHF, and hypertension
      Abbreviations: SAE: Serious Adverse Event; MAE: Minor Adverse Event
      Statistically significant (α = 0.05)

      Trends in Arthroscopic Rotator Cuff Repair

      When examining relative utilization, the proportion of patients undergoing arthroscopic rotator cuff repair procedures who identified as Black or African American significantly increased from 7.4% in 2010 to 10.4% in 2019 (ptrend< 0.0001) (Figure 1). Length of total hospital stay for both Black or African American (coefficient -0.11, p<0.001) and White patients (coefficient -0.08, p<0.0001) significantly decreased over the study period. There was no significant difference in length of stay between Black or African American and White patients (ARR: 1.03, 95% CI 0.88-1.19), and this association persisted over time (ptrend>0.05). Regarding rates of serious adverse events, they did not significantly change within patient populations over the study period, nor did they change between the two cohorts over the study period, (p>0.05 for both groups, ptrend>0.05).
      Figure thumbnail gr1
      Figure 1Trends in relative utilization of arthroscopic rotator cuff repair amongst Black and White patients between 2010 and 2019.

      DISCUSSION

      The results of this critical study add to the ever-growing evaluation of disparities between different racial groups in orthopedics. Specifically, the NSQIP database was utilized to compare procedure trends and perioperative measures between Black or African American and White patients undergoing arthroscopic rotator cuff repair in the United States. From 2010-2019, there was a significant increase in the proportion of Black or African American patients undergoing arthroscopic rotator cuff repairs. Despite differences in baseline demographics, we disproved our hypothesis as there was a nonsignificant impact on the rate of adverse events between cohorts. Additionally, demographic and clinical differences did not dictate the disparities observed in the study, as these differences persisted after adjustment.
      In the adjusted analyses, Black or African American patients were noted to have a statistically significant increase in odds for longer operative time (5.1 minutes) and time from operation to discharge (.04 days or 57.6 minutes), however, the clinical relevance of these findings will require further investigation. Of note, value-based healthcare has been a growing enterprise in the United States and future correlations with time-driven activity-based costing (TDABC) may reveal the true economic impact of these differences.
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      A multitude of baseline demographic factors were significantly different between Black or African American and White patients. Specifically, Black or African American patients exhibited higher rates of smoking, hypertension, and greater BMIs. Smoking has been noted in the literature to impair wound healing, reduce bone mass, and decrease spinal fusion.
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      Furthermore, Kashanchi et al demonstrated that smoking is a significant predictor of complications and readmission following arthroscopic rotator cuff repair.
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      Additionally, as reported by Ateschrang et al, a BMI > 30 is associated with higher re-tear rates after rotator cuff repair along with lower patient-reported outcome scores.
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      Lastly, the differences in hypertension between cohorts in this study is consistent with prior data, as a recent analysis by Aggarwal et al stated that the rate of hypertension is significantly higher in Black patients compared to White patients (45.3% vs. 31.4%).
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      While there is a paucity of similar literature for arthroscopic rotator cuff repair, previous studies have examined the impact of racial discrepancies in joint arthroplasty.
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      Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.
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      For example, Amen et al reported a large incongruity in utilization of hip arthroplasty based on race.
      • Amen T.B.
      • Varady N.H.
      • Rajaee S.
      • Chen A.F.
      Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.
      Moreover, there were significant differences between the complication rates of Black and White patients in knee arthroplasty, with the difference increasing from 2006 [6.1% vs 5.1%, respectively] to 2015 [6.0% vs 3.9%, respectively].
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      • Chen A.F.
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      Similarly, Best et al found that Black patients had increased odds of experiencing a multitude of adverse events, such as death [odds ratio (OR): 2.88] and acute myocardial infarction [OR: 1.43].
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      However, Schairer et al found that race did not have a significant effect on readmission in shoulder arthroplasty when comparing readmission rates amongst different racial groups.
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      Recently, a study performed by Johnson et al discussed the association of race on outcomes in arthroscopic rotator cuff repair from 2016-2018 using the NSQIP and TriNetX Research Network databases.
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      • Redziniak D.E.
      Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets.
      After propensity score matching, the study reported a significant difference in operative times between minority and White patients. While this study sheds critical insight into the impact of race in arthroscopic rotator cuff repair, it was particularly limited in its overall investigation timeframe and stratification of cohorts. Notable trends include significant decreases in operative times for both Black or African American and White patients as well as increased relative utilization for Black or African American patients from 2010-2019. There was a nonsignificant difference between changes in operative time over the study period, suggesting the original disparity persisted over time. Analysis of readmission, serious, and minor adverse events displayed nonsignificant differences between Black or African American and White patients. Moreover, despite a small, nonsignificant increase in serious adverse events over the study period for both patient cohorts, this trend was not significantly different between racial identities.
      A variety of factors have been referenced as possible causes for Black-White disparities. For example, previous literature has documented differences in medical understanding of joint surgery, significant distrust in the medical system, and a lack of cultural competence amongst physicians.
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      Some studies have postulated that Black patients may be more likely to engage in non-surgical forms of care, such as prayer and herbal medicine, when compared to White patients.
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      Importantly, multiple initiatives have been developed in order to combat discrepancies in healthcare, such as the AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium and the HHS Action Plan to Reduce Racial and Ethnic Health Disparities. In 2010, The AAOS/ORS/ABJS research symposium identified three main avenues to focus on in order to achieve their goal of lessening the burden of musculoskeletal disparities: increasing diversity in orthopedic staff, research, and education.
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      While there have been positive advances in the realm of arthroscopic rotator cuff repair over the past decade, there continues to be critical improvements. It is imperative for physicians and policymakers alike to construct realistic and meaningful initiatives in order to guarantee that every person, regardless of racial identity, receives the best possible care.

      Limitations

      While this study critically examines racial disparities in arthroscopic rotator cuff repair and benefits from its extended time period and large patient population, it is not without limitations. The NSQIP database is limited to capturing events within 30 days postoperatively, and thus may potentially underestimate rates of adverse events due to complications occurring outside of this time period. Moreover, the NSQIP database is restricted to evaluating adverse events strictly occurring in patients who seek medical care at participating institutions. Information regarding the clinical characteristics of the rotator cuff tears (i.e., size, chronicity, tendon quality, degree of retraction etc.) and specific details of the procedures (i.e., number and type of anchors, sutures, etc.) are not captured in the database and their potential impact could not be assessed. Furthermore, postoperative rehabilitation protocols are not incorporated in the NSQIP database, and their effect on certain complications (i.e., DVT) could not be evaluated. Lastly, as a result of the large number of patients included in this study, the analyses performed may reveal statistically significant differences that are not clinically significant. Despite these limitations, the NSQIP database has been used to provide novel, valuable insight for assessing operative and clinical characteristics as well as 30-day outcomes.
      • Bokshan S.L.
      • DeFroda S.F.
      • Owens B.D.
      Comparison of 30-Day Morbidity and Mortality After Arthroscopic Bankart, Open Bankart, and Latarjet-Bristow Procedures: A Review of 2864 Cases.
      ,
      • Eberlin C.T.
      • Varady N.H.
      • Kucharik M.P.
      • Naessig S.A.
      • Best M.J.
      • Martin S.D.
      Comparison of perioperative complications following surgical treatment of shoulder instability.
      ,
      • Goodloe J.B.
      • Traven S.A.
      • Johnson C.A.
      • Woolf S.K.
      • Nutting J.T.
      • Slone H.S.
      Increased Risk of Short-Term Complications and Venous Thromboembolism in Latarjet-Bristow Procedures Compared With Bankart Repairs.
      ,
      • Kucharik M.P.
      • Varady N.H.
      • Best M.J.
      • Rudisill S.S.
      • Naessig S.A.
      • Eberlin C.T.
      • et al.
      Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures.
      Importantly, the use of a large national database such as the NSQIP is essential for studies on national policy and disparities such as the present study. This is particularly important for studies on racial and socioeconomic disparities and studies that assess utilization, since smaller, single surgeon studies may not have adequate sample size and may not be generalizable to the national patient population.

      CONCLUSION

      With the increasing popularity of arthroscopic rotator cuff repair procedures, it is imperative to evaluate and address the influence of racial disparities. The difference in operative time and days from operation to discharge was statistically longer for Black or African American patients, however the clinical relevance of these findings remains unclear. Additionally, Black or African American patients constitute a relatively smaller proportion of arthroscopic rotator cuff repair patients, although this difference has significantly decreased over time. Further investigation is needed to fully understand and address causes of inequalities in arthroscopic rotator cuff repair in order to provide equitable care.

      Acknowledgments:

      The authors would like to express their sincerest gratitude to the Conine Family Fund for Joint Preservation. Additionally, the authors would like to thank Yanzhi Wang, PhD from the University of Illinois College of Medicine Research Services for her assistance with statistical analyses.

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