While total joint arthroplasty (TJA) procedures are considered successful in restoring function and alleviating pain in the hips and knees, there is still variability in outcomes among minority populations. In an attempt to improve outcomes, Carl L. Herndon, MD, an orthopedic surgeon at NewYork-Presbyterian and Assistant Professor of Orthopedic Surgery at Columbia, and his colleagues recently conducted a quality improvement initiative aimed at assessing a preoperative optimization protocol for TJA in a Medicaid Clinic.
Below, Dr. Herndon discusses the lessons learned from the initiative and suggests strategies to help achieve health equity in orthopedic surgery.
Research Background
It is well-known that racial and socioeconomic disparities exist within healthcare but there are unique challenges that underserved patients face when undergoing elective TJA. These include language barriers, insurance type, and geographical location as well as medical comorbidities such as diabetes, anemia, and obesity. Minority groups also tend to be at higher risk of postoperative complications.
We observed in previous studies that a nurse navigator can play a critical role in the optimization process; however there was a lack of research looking at the impact of such a role on TJA outcomes in our community. As an urban academic center that provides care to diverse patients, including an inner-city patient population, we see these disparities firsthand and wanted to find a way to address them so that the research can be used to ensure all patients have equitable access to quality care.
The Quality Improvement Initiative
Our goal was to test a preoperative optimization protocol for TJA, assess the effectiveness of that protocol, and highlight the challenges associated with caring for this population.
As part of a hospital-wide initiative, we hired a nurse navigator to enhance preoperative optimization for TJA candidates scheduled through the clinic. The team developed a risk stratification checklist for the nurse navigator to use to guide patients through the preoperative optimization process before scheduling surgery, and used the checklist to calculate a complexity score for each patient in order to determine whether surgery could be scheduled or if further medical care was needed. The nurse navigator also helped coordinate care with other medical specialties for those who had further medical needs.
As part of the study, we included two cohorts of patients that were divided into three groups in our retrospective analysis:
- Patients seen within the clinic prior to the implementation of the nurse navigator (Control-VC)
- Patient seen within the clinic after implementation of the nurse navigator (QI-VC)
- Patients scheduled through surgeons’ private offices for TJA (Control-P)
We utilized the Short Form Health Survey (SF-12) and Knee Society Scores (KSS) to obtain patient reported outcomes at three points of time: preoperative, three months postoperatively, and one year postoperatively.
Key Findings
We included 234 patients in our analysis – 39 patients from QI-VC – and 2:1 matched control with 78 patients from Control-VC. There were 117 patients in the Control-P group.
In the QI-VC group, 24 underwent primary TKA and 15 underwent primary THA. In the Control-VC group, 48 underwent primary TKA and 30 underwent primary THA. In the QI-VC group, 87% were female with an average age of 65 years, a BMI of 30.9kg/m², and an average America Society of Anesthesiologists (ASA) classification of 2. Additionally, 35.6% had a diagnosis of diabetes mellitus. In comparison, the Control-VC group was 67.9% female with an average age of 62 years, a BMI of 31.1kg/m², and an average ASA of 2. Within the Control-VC group, 20.5% had diabetes mellitus and 6.3% had chronic liver disease. There were 46.6% patients combined between the clinic groups that were Spanish-speaking as their primary language.
We collected data on the rate of complications to assess whether demographic factors influence postoperative outcomes. Rates of complications were similar between the Control-VC and QI-VC groups. However, the patients from the clinic cohort (Control-VC and QI-VC combined) experienced more postoperative complications than the Control-P group.
Clinic cohort complications were not reduced after hiring the nurse navigator and initiating this checklist. Additionally, the clinic patients, regardless of whether or not the nurse navigator/checklist were a part of their care, have increased complication rates compared to patients that are seen in the private office.
Study Implications
Our results showed that even with the full-time nurse navigator working to optimize patients preoperatively, they experienced no significant improvements in complication rates. This indicates to us that a traditional optimization pathway may not be the right approach for this setting. While this quality improvement initiative showed us this method was not effective in closing the gap to the patients from the private offices, it was still an incredibly important endeavor we undertook, and we learned a lot from it that will inform future care for underserved patients, allowing us to pivot resources to other efforts.
I think the biggest lesson we learned was that we need to ask the community what they need and try to meet them where they are to provide culturally competent care. This includes things like having someone who speaks the patient’s native language part of the care team, ensuring written materials are available in other languages, and understanding the physical barriers that they face in accessing care, such as lack of reliable transportation, chaperones, and work constraints.
Our results are an addition to existing literature on health disparities and accessing care, and can serve as a call to other payers, a call to the government, or a call to whoever can use this data to advocate for our patients.
Looking at the Future
More infrastructure and opportunities are needed to try and close this gap and eliminate health disparities in our community. The only way we can learn and improve is to continue to try new approaches and publish and share the findings - whether or not they’re successful – with our peers to learn from.
Since we tested this QI initiative, we have made some improvements to the clinic. It’s in a new location in Washington Heights and there’s more interdisciplinary aspects to it with surgery, physical therapy, occupational therapy, and orthotists all located in the same facility. We hope that by having everything in one location, that can help patients overcome some of the physical barriers to care that they face with multiple appointments at different locations.
We are also continuing to look at other ways we can improve care for our patients. One of my NewYork-Presbyterian and Columbia colleagues, Nana O. Sarpong, MD, MBA, is currently conducting a project looking at the diversity of our surgeons and how that affects the diversity of the patient populations that we treat. Preliminary findings from this research suggests that a more diverse faculty leads to a more diverse patient population, and there are no negative impacts on patient outcomes.
As a field, we take an oath when we graduate from medical school to do no harm, making sure that patients receive the same level of care same regardless of their race, ethnicity, insurance type, or socioeconomic background. Being able to provide the same level of care for all patients is incredibly important and something we are all constantly striving to do here at NewYork-Presbyterian and Columbia.
