• Media type: E-Article
  • Title: Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race
  • Contributor: Gitajn, Ida Leah; Werth, Paul; Fernandes, Eseosa; Sprague, Sheila; O'Hara, Nathan N.; Bzovsky, Sofia; Marchand, Lucas S.; Patterson, Joseph Thomas; Lee, Christopher; Slobogean, Gerard P.; Slobogean, Gerard P; Sprague, Sheila; Wells, Jeffrey; Bhandari, Mohit; Harris, Anthony D; Mullins, C Daniel; Thabane, Lehana; Wood, Amber; Della Rocca, Gregory J; Hebden, Joan; Jeray, Kyle J; Marchand, Lucas S; O'Hara, Lyndsay M; Zura, Robert; [...]
  • Published: American Medical Association (AMA), 2022
  • Published in: JAMA Network Open
  • Extent: e2244357
  • Language: English
  • DOI: 10.1001/jamanetworkopen.2022.44357
  • ISSN: 2574-3805
  • Keywords: General Medicine
  • Abstract: <jats:sec id="ab-zoi221251-4"><jats:title>Importance</jats:title><jats:p>Racial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.</jats:p></jats:sec><jats:sec id="ab-zoi221251-5"><jats:title>Objective</jats:title><jats:p>To assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.</jats:p></jats:sec><jats:sec id="ab-zoi221251-6"><jats:title>Design, Setting, and Participants</jats:title><jats:p>This cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.</jats:p></jats:sec><jats:sec id="ab-zoi221251-7"><jats:title>Exposures</jats:title><jats:p>Patient-level and hospital-level race, ethnicity, and insurance status.</jats:p></jats:sec><jats:sec id="ab-zoi221251-8"><jats:title>Main Outcomes and Measures</jats:title><jats:p>Primary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.</jats:p></jats:sec><jats:sec id="ab-zoi221251-9"><jats:title>Results</jats:title><jats:p>A total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; <jats:italic>P</jats:italic> = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; <jats:italic>P</jats:italic> = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; <jats:italic>P</jats:italic> = .79).</jats:p></jats:sec><jats:sec id="ab-zoi221251-10"><jats:title>Conclusions and Relevance</jats:title><jats:p>In this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.</jats:p></jats:sec>
  • Description: <jats:sec id="ab-zoi221251-4"><jats:title>Importance</jats:title><jats:p>Racial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.</jats:p></jats:sec><jats:sec id="ab-zoi221251-5"><jats:title>Objective</jats:title><jats:p>To assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.</jats:p></jats:sec><jats:sec id="ab-zoi221251-6"><jats:title>Design, Setting, and Participants</jats:title><jats:p>This cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.</jats:p></jats:sec><jats:sec id="ab-zoi221251-7"><jats:title>Exposures</jats:title><jats:p>Patient-level and hospital-level race, ethnicity, and insurance status.</jats:p></jats:sec><jats:sec id="ab-zoi221251-8"><jats:title>Main Outcomes and Measures</jats:title><jats:p>Primary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.</jats:p></jats:sec><jats:sec id="ab-zoi221251-9"><jats:title>Results</jats:title><jats:p>A total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; <jats:italic>P</jats:italic> = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; <jats:italic>P</jats:italic> = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; <jats:italic>P</jats:italic> = .79).</jats:p></jats:sec><jats:sec id="ab-zoi221251-10"><jats:title>Conclusions and Relevance</jats:title><jats:p>In this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.</jats:p></jats:sec>
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  • Access State: Open Access