Summary

Contrary to prior US studies, this retrospective review of 3304 hip and knee arthroplasties found that minorities in Hawaii do not have decreased utilization rates or increased perioperative complication rates compared to the majority population.

Abstract

Introduction

Previous racial disparity evaluations of total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) have focused on black and white populations. The current study reports the utilization and perioperative compilations in Hawaii’s population of majority Asians, with subpopulations of Whites, Native Hawaiian/Pacific-Islander (NHPI) and Blacks.

Methods

Data were retrospectively collected from 3304 arthroplasties performed from 2011 to 2019 and compared across four major ethnic groups.

Results

Racial groups included 1789 (52.2%) Asians, 1164 (34%) Whites, 320 (9.3%) NHPI and 31 (0.9%) Blacks. Medicare was the most common insurance type for Asians (66.2%) and Whites (54.2%), while private insurance was most common for NHPI (49.4%) and Blacks (54.8%). Asians were significantly older (Asian: 69.7; White: 66.7; NHPI: 64.0; Black: 59.7; p<0.001), had significantly lower body mass index (Asian: 27.9; White: 28.8; NHPI: 33.0; Black: 34.3; p<0.001) and had the greatest percentage of patients with impaired fasting glucose (Asian: 46.8%; Whites: 26.2%; NHPI: 46.6%; Black: 40.0%; p<0.001). Normalized to total Hawai‘i population and racial percentage, male arthroplasty utilization rate increased from 2011 to 2019 0.14 (Asian), 0.07 (White) and 0.24 (NHPI) arthroplasties per 1000 persons. Female arthroplasty utilization rate also changed 0.08 (Asian), -0.01 (White) and 0.14 (NHPI) arthroplasties per 1000 persons. Compared to Asians, Whites had increased odds of undergoing THA compared to TKA/UKA (OR: 1.755, CI: 1.532-2.009; p<0.001). Compared to Asians, Whites and NHPI had increased odds of undergoing TKA over UKA (White: OR: 1.499, CI: 1.204-1866; NHPI: OR: 2.013, CI: 1.402-2.887; p<0.001). From 2012-2015 Asians utilization rates of TKA ranged from 53.8%- 62.4% but dropped to 30.9%-37.9% following the introduction of the UKA procedure in 2016 which was utilized in 27.6%-32.7% of patients from 2016 to 2019. After controlling for bilateral procedures, only NHPI had a lower risk of transfusion compared to Asians (OR: 0.478, CI: 0.266-0.860; p=0.014). Only Whites had increased risk of wound or systemic complications compared to Asians (OR: 2.086, CI: 1.242-3.503, p=0.005). There was no difference between racial groups and length of stay in unilateral knee replacements. When controlling for bilateral knee replacements, Whites had increased length of stay at 2.66 days compared to Asians at 2.19 days (p=0.005).

Discussion

Minority racial groups in Hawaii have equal utilization of joint arthroplasty and, despite increased body mass index and impaired fasting glucose rates, had no increased rates of peri-operative complications. White patients more frequently underwent THA and Asian patients most commonly utilized UKA once made available in 2016. Asians and Whites tended to be older at time of surgery and were covered by Medicare while NHPI and Blacks were younger and covered by private insurance.