Transcription:
Racial and Ethnic Disparities in Orthopaedic Outcomes

Melanie Cole: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we're discussing racial and ethnic disparities in orthopedic outcomes. Joining me is Dr. Linda Suleiman. She's an Assistant Professor of Orthopedic Surgery and Director of Diversity and Inclusion at Magog Medical Center of Northwestern University. Dr. Suleiman, it's a pleasure to have you join us again today. Tell us a little bit about your role as the director of diversity and inclusion at Northwestern Medicine and the work that you're doing to help diversify the field of orthopedics.

Dr. Suleiman: Good morning. My name is Linda Suleiman and I serve as a director of diversity inclusion for Magog. My specialty training is in joint replacements, specifically hip and knee replacements. And my role as director of diversity inclusion is within our residents and fellows. So our house staff or our trainees who are in their subspecialties before they go on and practice on their own. And my primary job is to really create a culturally competent learning environment for our residents and fellows, as well as recruitment and retention of underrepresented minorities to the field of orthopedics, as well as across all specialties.

Host: Well, thank you for telling us about your role in much of your research. This year is focused on the disparities in orthopedic outcomes. Tell us about the background of your work Dr. Suleiman, and some of the methods that you used.

Dr. Suleiman: Sure. So most of the majority of my research is within health disparities and health equity within total knee and total hip replacements. We have a bundled payment system that was rolled out by the center of Medicare services, CMS across the country where joint replacement is now a bundled payment system where you are essentially given one fee and the surgery is bundled. And essentially you have to have pretty good outcomes to do well in this new bundled service. And what I started noticing is that nationally, surgeons were kind of picking and choosing more healthy patients who would likely have the best outcomes. And a lot of these patients happen to be Caucasian males and females and less so from other racial ethnic backgrounds. And so my thought was in my own just personal experiences that I was seeing less patients of color receiving hip and knee replacements.

And we already knew in the literature well before bundled payments rolled out that there was access issues where patients of racial and ethnic minorities were less likely to undergo a hip and knee replacement, but we did not know why. And in my thoughts on looking at this was really looking at the Illinois hospital database and seeing, well, what are the outcomes for patients of racial and ethnic backgrounds, African American patients as well, Latin X patients. And what we found is that patients of these ethnic backgrounds had longer length of stay and higher complication risks postoperatively and they were also more likely to be discharged to a rehab facility rather than home. And so really, you know, my thought behind looking at this work is how can we better optimize groups of African American patients, as well as Latin X patients to have better outcomes and what can we do to really optimize them preoperatively for surgery so that they have better outcomes?

Host: What a great topic and a great area of study, it's so important and needed right now. Dr. Suleiman tell us a little bit about the patient characteristics or factors that you found that may contribute to poor physical function, infection, other complications, readmission, and while you're telling us that what physical function differences did you notice does adherence to rehab along those lines, does that play a significant role? Support system after surgery? Speak about all of those factors that come into play?

Dr. Suleiman: Sure. So what we found is patients with higher body mass index obesity patients who are diabetics, as well as respiratory conditions like COPD and cardiovascular risks have higher postoperative complications. And what we know nationally is that patients of color tend to have those disease processes. And what I think about is race as a social construct and not a biological construct, it's, it's how patients are living, their socioeconomic status or family structure that all play a role in their health condition. So what I really do believe is that for joint replacement specifically within orthopedics, you know, if we're able to optimize patients in our preoperative clinics, having patients who come see me most of the time may or may not even have a PCP. So it's establishing long-term care and having close follow-up with patients of color who have these medical complexities so that they do better postoperatively.

I think from a rehab standpoint you know, we've made it a little bit easier with having some home health services available, but not all health insurances may not cover those services where you can have a physical therapist come to your home the first three weeks and a nurse check on you the first three weeks after surgery. And that has helped with our rehab protocols, I would say in my own practice. But really, you know, a lot of our patients of color, what we know in Chicago work more of the essential services than these white, I'd say, white collar jobs. And that's what we know from our census databases here in Chicago. So it's hard to take time off of work. It's hard to be able to lose that income if you don't have short term disability policies. And most patients are living in the households who you need to support your family and you need to work, which is a component of, I think, why most patients have this fear of going under surgery.

Host: It makes perfect sense. And you've explained very well. Why some of these disparities exist. Have you seen differences in the utilization of certain orthopedic procedures or treatments based on those comorbid conditions or support system or adherence or any of those things you mentioned?

Dr. Suleiman: You specifically know that there's under utilization of hip and knee replacements, despite worst deformities in patients of color, the patients who have more severe deformities, worse arthritis are accessing surgery for hip and knee replacement that would better their functional outcomes less so than a Caucasian patient.

Host: So now let's talk about orthopedic surgeons for a minute, Dr. Suleiman, do you think awareness of these disparities is low or high among orthopedic surgeons? And depending on your answer, tell us what you'd like to see change and what role the surgeon can play in reducing those disparities in the outcomes.

Dr. Suleiman: You know, orthopedic surgery is still one of the least diverse subspecialties, as far as gender and racial, ethnic minorities. Our specialties, only 6% women, and of that 0.04% black women. And from a racial ethnic standpoint surgeons of color, African American surgeons like myself are 1.5% of the entire population of orthopedic surgeons in this country. And what we know from a research standpoint is that patient's perception and understanding of their care is better from a patient standpoint when they report how they perceive the information about surgery from doctors who look like them. And so if we, as orthopedic surgeons, don't represent our patient population, we're just going to exacerbate these health disparities. So do I believe that health orthopedic surgeons nationally know that there's a disparity?

Yes. I think the best way that we can overcome this is knowing what our individual implicit biases and every single orthopedic surgeon, every single doctor has implicit biases. No one is exempt from that. So whether you're a white surgeon, black surgeon, man, or woman, we all have our implicit biases. And I think how we overcome these health disparities is really knowing how we deliver care and is there bias in how we deliver that care? So there's several options, there's implicit association testing that we can individually take. So we know what we preference from a gender ethnic standpoint. And if we know what our own biases are, we can overcome that when we're having these discussions with patients.

Host: Absolutely. Dr. Suleiman, so well said as we wrap up what's next, when it comes to this area of study, or what would you like to summarize? And what would you like other providers to take away from this very important segment on racial and ethnic disparities in orthopedic outcomes?

Dr. Suleiman: I think the main takeaway is patients of color with worst deformities, worst knee problems, worse hip problems specifically, you know, tend to go to their emergency department or their primary care doctor or urgent care centers for their acute exacerbations of the underlying orthopedic problem. And I think if we, as a healthcare system, we as a society, can program to expedite referrals to orthopedic surgeons, I think that could overcome some of these issues, but I think early referral and early education of the underlying orthopedic problem, and early discussions with an orthopedic surgeon, I think we'll be able to overcome these disparities.

Host: Absolutely. Thank you so much, Dr. Suleiman for joining us today and sharing your expertise and your studies on this very important topic. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient, please visit our website at NM.org to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.