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The Impact of the COVID-19 Pandemic on Racial Disparities in Patients Undergoing Total Shoulder Arthroplasty in the United States

Open AccessPublished:November 11, 2022DOI:https://doi.org/10.1016/j.jseint.2022.10.014

      Abstract

      Introduction

      The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the US and to determine whether these disparities were affected by the COVID-19 pandemic.

      Methods

      Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April-December from 2019-2020. Utilization was assessed for White/Black/Hispanic/Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age/sex/CMS-Hierarchical Condition Categories (HCC) score, dual enrollment (proxy for socioeconomic status), time fixed effects, and Core-based Statistical Area (CBSA) fixed effects was used to study difference across groups.

      Results

      In 2019, TSA volume/1000 beneficiaries was 1.51 for White and 0.57 for non-White, a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P<0.01). There was an overall 14% decrease in TSA volume/1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference;8.7%,p = 0.02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%,p = 0.05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture.

      Conclusions

      During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA while disparities were less apparent for proximal humerus fracture.

      Keywords

      Racial disparities have been shown in many areas of medicine and have persisted through the past decade.
      • Best M.J.
      • McFarland E.G.
      • Thakkar S.C.
      • Srikumaran U.
      Racial Disparities in the Use of Surgical Procedures in the US.
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      Disparities in Outcomes for African Americans and Whites Undergoing Total Knee Arthroplasty: A Systematic Literature Review.
      ,
      • Jha A.K.
      • Fisher E.S.
      • Li Z.
      • Orav E.J.
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      Racial trends in the use of major procedures among the elderly.
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      The influence of race and ethnicity on complications and mortality after orthopedic surgery: a systematic review of the literature.
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      Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data.
      Achieving health equity and improving access to quality medical care for underrepresented minorities has been a focus for medical societies, patient advocacy groups, and various areas of government, prompting the development of federal programs and policies aimed at reducing health inequality.

      Anon. Movement Is Life caucus. Movement Is Life: a catalyst for change. Addressing musculoskeletal health disparities. 2011. 2019.

      Anon. NIAMS National Institute of Arthritis Musculoskeletal and Skin Diseases. Department of Health and Human Services Strategic Pan for Reducing Racial Disparities. 2006.

      Anon. U.S. Department of Health and Human Services. HHS action plan to reduce racial and ethnic disparities: a nation free of disparities in health and health care. http://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf. Published April 2011. Accessed June 15, 2020.

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      Despite knowledge of racial disparities and the implementation of various policies and methods to reduce them, racial disparities have persisted in the US for a myriad of surgical procedures including shoulder arthroplasty.
      • Amen T.B.
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      • Chen A.F.
      Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 to 2015.
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      • 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.
      The onset of the coronavirus-19 (COVID) pandemic has led to widespread economic and healthcare crises affecting patients, providers, and the healthcare system overall.
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      Covid-19 - Implications for the Health Care System.
      Several reports have demonstrated that the Black community has been disproportionately affected by COVID-19 both in rates of hospitalization and risk of death.
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      Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges.
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      Failing Another National Stress Test on Health Disparities.
      ,
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      Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs.
      Price-Haygood et al showed that Black patients with COVID-19 had a significantly higher mortality rate than White patients within a large, tertiary care network.
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      • Fort D.
      • Seoane L.
      Hospitalization and Mortality among Black Patients and White Patients with Covid-19.
      This finding was particularly problematic given that Black patients made up less than one-third of the population studied. Worsening racial disparities during the COVID-19 pandemic have also been shown for Medicare patients undergoing hip and knee replacement surgery, with a 12.9% decreased likelihood of undergoing hip or knee replacement for non-White patients.
      • Stronach B.M.
      • Zhang X.
      • Haas D.
      • Iorio R.
      • Anoushiravani A.
      • Barnes C.L.
      Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic.
      The purpose of this study was to assess the impact that the COVID-19 pandemic has had on racial disparities in patients undergoing total shoulder arthroplasty (TSA). We also aim to evaluate these disparities in the context of indication for shoulder arthroplasty, comparing those treated for proximal humerus fracture with non-fracture cases. We hypothesize that shoulder arthroplasty utilization for all races decreased during the COVID pandemic but that a greater decrease occurred in Black, Hispanic, and Asian patients, compared with White patients.

      Methods

      Data Source

      The Center for Medicare and Medicaid Services (CMS) fee-for-service (FFS) inpatient and outpatient claims data 100% sample, and Medicare enrollment data spanning 2019 through 2020 was used for this analysis. We identified April 2020 as the first full month after the onset of the COVID-19 pandemic, and therefore set April 1, 2020 as the start date for the COVID-19 period. Since at the time of our analysis, the claims data extended through December 31, 2020, we examined cases admitted by December 18th to ensure we could capture the full length of stay. We examined the same time period of cases (April 1st to December 18th admissions) in 2019 as in 2020 to ensure comparability between the years. The study included primary total shoulder arthroplasties (TSAs) that were coded as inpatient using diagnosis-related group (DRG) 483, and outpatient using primary current procedural terminology (CPT) 23472. Outpatient TSAs only made up only a small fraction of total TSAs cases as CMS only removed TSAs from the inpatient-only list in 2021. We further divided TSAs into non-fracture anatomic arthroplasties, non-fracture reverse arthroplasties, and fracture TSAs (anatomic and reverse combined) based on each case’s primary international classification of diseases 10th revision diagnosis (ICD-10-CM) and procedure (ICD-10-PCS) codes. CMS previously expanded their variables for non-white and non-black race and ethnicity groups to allow for more granular data collection. Therefore, we analyzed racial and ethnic groups individually (White, Black, Hispanic, Asian) as well as in larger groups (White and non-White)

      Race/Ethnicity

      We defined race and ethnicity using the race variable from the Medicare beneficiary enrollment data. Race and ethnicities include White, Black, Hispanic, Asian, other, and unknown. We grouped minorities including Black, Hispanic, Asian, and other into the non-White racial group to compare with the White racial group. We also compared Black, Asian, Hispanic, and other minority groups with White separately.

      Statistical Analysis

      We calculated the total TSA volume per 1000 Medicare beneficiaries by different racial groups. We then compared the total TSA rate between April 1st and December 18th in 2019 and 2020. The percentage change in TSA rate during-COVID was then calculated. A generalized linear model assuming a binomial distribution at beneficiary-year level was fitted with the dependent variable being if a beneficiary received a TSA between April and December during the given year. We adjusted for the minority indicator interacted with during-COVID, age, sex, CMS-hierarchical condition categories (HCC) risk score, Medicare-Medicaid dual enrollment status, and year fixed effects to study the differential effect of COVID-19 on operation rate changes across different racial populations. Bonferroni corrections were applied to p-values. We controlled for the CMS-HCC risk score because it is a measure reflecting the expected future health costs for each patient based on the patient demographics and chronic illnesses. Medicare-Medicaid dual enrollment, i.e. if a patient is enrolled in both Medicare and Medicaid, was controlled for as a proxy for economic status of the beneficiary since eligibility is income based The coefficient of the interaction term between minority and during-COVID is our estimate of the impact of the COVID-19 pandemic on racial disparities between White and the minority racial population, meaning that compared to the White racial group, how much did the TSA operation rate change due to COVID-19 in the minority racial population.

      Results

      A total of 49,412 and 41,554 cases were observed in 2019 and 2020 between April and December, respectively. There has been an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries between 2019 and 2020 (1.51 vs. 1.30). Racial disparities existed for TSA nationally prior to the COVID-19 pandemic. In 2019, the TSA hospitalization volume per 1000 Medicare beneficiaries was 1.69 for the White population and 0.57 for non-White, a 2.6-fold difference. In 2020, the White TSA hospitalization rate (0.45 per 1000 beneficiaries) was 2.9 times higher than that of the non-White patients (0.45 per 1000 beneficiaries) during the COVID-19 pandemic. The percentage decrease between 2019 and 2020 for White and non-White was 14% and 21%, respectively (Table 1).
      Table 1Changes in Rates of TSAs per 1000 Medicare Beneficiaries by Racial Group During the COVID-19 Pandemic
      2019 Apr-Dec2020 Apr-DecChange (%)
      All TSA (Sum of Types Below)1.511.30-14%
       White1.691.46-14%
       Non-white0.570.45-21%
      Black0.580.45-22%
      Hispanic0.500.42-16%
      Asian0.290.22-25%
      Other Minorities0.820.68-17%
       Unknown1.311.16-11%
      Types of Hospitalizations
      Anatomic TSA Non-fracture0.450.36-19%
       White0.500.40-19%
       Non-white0.160.11-29%
      Black0.180.12-29%
      Hispanic0.110.08-31%
      Asian0.070.05-35%
      Other Minorities0.210.16-23%
       Unknown0.510.45-11%
      Reverse TSA Non-fracture0.910.80-13%
       White1.020.89-13%
       Non-white0.360.29-19%
      Black0.380.30-20%
      Hispanic0.320.28-12%
      Asian0.170.12-30%
      Other Minorities0.530.44-17%
       Unknown0.720.64-12%
      Anatomic + Fracture TSA Fracture0.150.15-3%
       White0.170.17-3%
       Non-white0.040.04-4%
      Black0.030.03-5%
      Hispanic0.060.06-11%
      Asian0.050.059%
      Other Minorities0.080.08-6%
       Unknown0.070.07-4%
      Similar trends were observed when breaking the arthroplasties into anatomic and reverse TSAs. For anatomic TSAs, the overall decrease was 19% between 2019 and 2020, with the White populating decreasing by 19%, and the non-White populating decreasing by 29%. For reverse TSAs, a 13% decrease was observed across populations between 2019 and 2020, with a 13% decrease for White and 19% decrease for non-White. Disparities were less apparent when analyzing non-elective cases, with a 3% decrease overall, a 3% decrease among White patients compared with a 4% decrease for non-White patients undergoing shoulder arthroplasty for proximal humerus fracture (Table 1).
      By fitting a logistic regression at beneficiary-year level with receiving a TSA as dependent variable, we were able to quantify the impact of COVID-19 and race combined. Table 2 shows the estimate of the interaction term between COVID-19 and minorities, quantifying the exacerbation of preexisting racial disparities due to COVID-19. When pooling all non-White patients, the estimated difference in TSA utilization compared with White was -8.7% (95% CI [-14.0%, -3.1%], p = 0.02), meaning that with TSA utilization decreasing for both White and non-White, there was an 8.7% more decrease for the non-White population. This effect was especially pronounced for the Black population, with a -10.1% (95% CI [-16.8%, -2.9%], p = 0.05) estimated difference compared with White. For other minorities, however, we did not observe significant differences according to the regression.
      Table 2Estimated Between-group Differences of TSA Rates for All Types of TSAs For Each Minority Group Compared with the White Population
      • 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.: A Comprehensive Analysis of Trends from 2006 to 2015.
      Estimate95% CIP-value
      Non-white vs. White-8.7%(-14.0%, -3.1%)0.02
      Black vs. White-10.1%(-16.8%, -2.9%)0.05
      Hispanic vs. White-2.6%(-17.3%, 14.8%)1.00
      Asian vs. White-18.2%(-34.7%, 2.4%)0.64
      Other Minorities vs. White-4.5%(-15.7%, 8.3%)1.00
      1. Estimated between-group differences for operation rate were made from the logistic regression model at beneficiary-year level, adjusted for age, sex, CMS-HCC risk score, and Medicare-Medicaid dual enrollment status. Bonferroni corrections were applied to p-values. Coefficients were converted as the percentage differences in probability of receiving a TSA for minorities compared to White. The comparisons were made based on April through December data for 2020 and 2019.

      Discussion

      This study showed that after the onset of the COVID-19 pandemic, preexisting racial disparities in patients undergoing TSA worsened. The overall rate of TSA hospitalization decreased by 14% across racial groups during the COVID-19 pandemic. However, the White population experienced a decrease of 14%, compared with a decrease of 21% in the non-White population. When analyzing disparities by indication for surgery, disparities were less pronounced in patients undergoing arthroplasty for proximal humerus fracture, with a decrease in rate of 3% and 4% for White and non-White patients respectively. After controlling for age, sex, comorbidities, and dual enrollment status (a proxy for economic status), the estimated difference in percent decrease between White and non-White patients was 8.7%, indicating that the non-White population had an 8.7% larger decrease in rate of hospitalization than White patients. The estimate was 10.1% for the Black patients.
      Racial disparities have been shown in many studies throughout the orthopedic and general medical literature.
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      Racial differences were less apparent in patients undergoing arthroplasty for proximal humerus fracture with a decrease of 3% in White patients and 4% in non-White patients during the pandemic. Many shoulder arthroplasty cases performed for proximal humerus fracture are not elective surgeries and the difficulty in access to subspecialty orthopedic care may not be as marked in the trauma setting. However, racial disparities have been shown in multiple studies for patients undergoing fracture care.
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      ,
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      • Chen A.F.
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      ,
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      • Elmi H.
      • John V.
      • Dabney K.W.
      Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges.
      ,
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      • Carmona R.
      • Pomeroy C.
      Failing Another National Stress Test on Health Disparities.
      ,
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      • Burton J.
      • Fort D.
      • Seoane L.
      Hospitalization and Mortality among Black Patients and White Patients with Covid-19.
      ,
      • Stronach B.M.
      • Zhang X.
      • Haas D.
      • Iorio R.
      • Anoushiravani A.
      • Barnes C.L.
      Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic.
      ,
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      • Wadhera P.
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      • Figueroa J.F.
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      • Shen C.
      Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs.
      In a large cohort of patients within an integrated-delivery healthcare system, 77% of patients hospitalized with Covid-19 and 71% of those who died were Black despite the fact that Black patients comprised only 31% of the health-system population in the study.
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      These findings were corroborated in another study which showed that 34% of Covid deaths were among Black patients despite this group accounting for only 12% of the population in the United States.
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      • John V.
      • Dabney K.W.
      Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges.
      These studies highlight that the Covid-19 pandemic has magnified another pandemic in the US, which is racial and ethnic disparities in healthcare.
      • Williams D.R.
      • Cooper L.A.
      COVID-19 and Health Equity-A New Kind of “Herd Immunity.
      There are several explanations for the findings of this study which have been posited as reasons for healthcare disparities throughout the pandemic. Access to primary care and specialty care has been shown to be more difficult for under-represented minorities.
      • Owen W.F.
      • Carmona R.
      • Pomeroy C.
      Failing Another National Stress Test on Health Disparities.
      ,
      • Williams D.R.
      • Cooper L.A.
      COVID-19 and Health Equity-A New Kind of “Herd Immunity.
      Implicit bias is associated with worse quality of care and poorer communication between patients and physicians.
      • Hall W.J.
      • Chapman M.v.
      • Lee K.M.
      • Merino Y.M.
      • Thomas T.W.
      • Payne B.K.
      • Eng E.
      • Day S.H.
      • Coyne-Beasley T.
      Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.
      ,
      • Maina I.W.
      • Belton T.D.
      • Ginzberg S.
      • Singh A.
      • Johnson T.J.
      A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.
      ,
      • Williams D.R.
      • Cooper L.A.
      COVID-19 and Health Equity-A New Kind of “Herd Immunity.
      Bias in behavioral attitudes can be worsened under conditions of stress such as providing medical care during the Covid-19 pandemic.
      • Williams D.R.
      • Cooper L.A.
      COVID-19 and Health Equity-A New Kind of “Herd Immunity.
      This may be reflected in data from various regions in the US which showed that African American patients with cough or fever were less likely than White patients to be offered a Covid test.

      Anon. Farmer B. The coronavirus doesn’t discriminate, but U.S. health care showing familiar biases. NPR. Published April 2, 2020. Accessed October 1, 2021. https://www.npr.org/sections/health-shots/2020/04/02/825730141/the-coronavirus-doesntdiscriminate-but-u-s.

      Another factor contributing to racial disparities which may be exacerbated during the Covid-19 pandemic is pathogenic effects of adverse living and working conditions.
      • Owen W.F.
      • Carmona R.
      • Pomeroy C.
      Failing Another National Stress Test on Health Disparities.
      Data from New York City showed that the Bronx had the lowest income and education levels, the highest population of under-represented minorities, and the highest rate of Covid-19 hospitalizations and deaths, despite a lower population density than Manhattan.
      • Wadhera R.K.
      • Wadhera P.
      • Gaba P.
      • Figueroa J.F.
      • Joynt Maddox K.E.
      • Yeh R.W.
      • Shen C.
      Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs.
      Finally, distrust in the medical system has been shown as a factor contributing to racial disparities in patients contemplating total knee replacement and may influence decisions for patients considering total shoulder replacement as well.
      • Chang H.J.
      • Mehta P.S.
      • Rosenberg A.
      • Scrimshaw S.C.
      Concerns of patients actively contemplating total knee replacement: differences by race and gender.
      Although the results of the present study do not provide reasons for the worsening racial disparities in patients undergoing TSA during the Covid pandemic, they do highlight and raise awareness of this important issue. A recent viewpoint by Yancy recommends three strategies for helping to reduce racial disparities in healthcare, the first of which is to raise awareness of the problem.
      • Yancy C.W.
      COVID-19 and African Americans.
      Another strength of this study is that many factors such as age, sex, and economic status, or dual-enrollment status, were controlled for in our regression analysis. Although we do not have specific socioeconomic variables such as household income, dual enrollment status is based on income and can be used to as an indicator of socioeconomic status.
      Despite these strengths this study has several limitations. One, we were not able to study these racial trends across different geographic regions or census divisions. Since the overall incidence of TSA in the Medicare population is < 2 per 1000 beneficiaries, this did not provide sufficient sample size for accurate census division analysis. In addition, the patient population studied included Medicare beneficiaries but not private payers. This may have been beneficial in this study since a larger proportion of patients with private insurance may have undergone outpatient TSA. Among Medicare beneficiaries in our study period from 2019-2020, the percentage of outpatient TSA was just 1.4%, indicating a large catchment of our study sample.

      Conclusion

      COVID-19 exacerbated the preexisting racial disparities for TSA utilization among Medicare beneficiaries in the US. During the COVID-19 pandemic, the overall TSA hospitalization rate dropped by 14% across racial groups. However, COVID-19 impacted racial groups differently, with the White population experiencing a decrease of 14%, and the non-White population experiencing a decrease of 21%. This trend was observed for elective shoulder arthroplasty cases while disparities were less apparent in patients undergoing arthroplasty for proximal humerus fractures.

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