Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States

Background: The most comprehensive health care policy changes aimed at reducing racial disparities were implemented in 2011 and continue today. It is unknown if these initiatives have led to a decrease in racial differences among patients undergoing total shoulder arthroplasty. The purpose of this study is to examine racial differences in procedural rates, complications, and mortality in patients undergoing total shoulder arthroplasty. Methods: National rates of utilization of primary anatomic (TSA) and reverse total shoulder arthroplasty (RTSA) were analyzed from 2012 to 2017. Population-adjusted and gender-adjusted procedural rates were trended over time and standardized based on insurance status. Multivariable logistic regression was used to determine racial differences in complications and mortality. Results: In 2012, the incidence of TSA and RTSA among white patients was 18.7/100,000 compared to 5.1/100,000 among black patients (difference: 13.6/100,000) and increased to 36.9/100,000 in white patients and 10.8/100,000 in black patients in 2017 (difference: 26.1/100,000). This equated to an increase in the race disparity by 12.5/100,000 over the study period. Blacks underwent lower rates of TSA and RTSA than whites regardless of insurance status. Black patients had a longer length of hospital stay and a higher rate of discharge to facility. Black patients had increased odds of complications, including acute myocardial infarction (odds ratio [OR] 1.43), pulmonary embolism (OR 1.97), acute renal failure (OR 1.40), sepsis (OR 1.68), and surgical site infection (OR 2.19). Black patients had increased odds of mortality compared with white patients (OR 2.88). Conclusion: Racial disparities in patients undergoing TSA and RTSA are worsening over time. Black patients undergo TSA and RTSA at lower rates than white patients regardless of insurance status and have increased odds of complications and mortality. Improved initiatives are needed to reduce these racial disparities and further research is warranted to understand their root causes. Level of evidence: Level III; Large Database Analysis; Epidemiology Study (c) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.