Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race
Authors: 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. ,   PREP-IT Investigators, 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 , Lee Christopher , Patterson Joseph , Gardner Michael J , Blasman Jenna , Davies Jonah , Liang Stephen , Taljaard Monica , Devereaux PJ , Guyatt Gordon H , Marvel Debra , Palmer Jana , Friedrich Jeff , O'Hara Nathan N , Grissom Ms Frances , Gitajn I Leah , Morshed Saam , O'Toole Robert V , Petrisor Bradley A , Mossuto Franca , Joshi Manjari G , D'Alleyrand Jean Claude , Fowler Justin , Rivera Jessica , Talbot Max , Dodds Shannon , Li Silvia , Pogorzelski David , Rojas Alejandra , Del Fabbro Gina , Szasz Olivia P , Heels Ansdell Diane , McKay Paula , Murphy Kevin , Howe Andrea , Demyanovich Haley , Kettering Eric , Polk Genevieve , Medeiros Michelle , Eglseder Andrew , Johnson Aaron , Langhammer Christopher , Lebrun Christopher , Nascone Jason , Pensy Raymond , Pollak Andrew , Sciadini Marcus , Degano Yasmin , Demyanovich Haley K , Phipps Heather , Hempen Eric , Petrisor Brad A , Johal Herman , Ristevski Bill , Williams Dale , Denkers Matthew , Rajaratnam Krishan , Al-Asiri Jamal , Gallant Jodi , Pusztai Kaitlyn , MacRae Sarah , Renaud Sara , Natoli Roman N , McKinley Todd O , Virkus Walter W , Sorkin Anthony T , Szatkowski Jan P , Mullis Brian H , Jang Yohan , Lopas Luke A , Hill Lauren C , Fentz Courteney L , Diaz Maricela M , Brown Krista , Garst Katelyn M , Denari Emma W , Osborn Patrick , Pierrie Sarah , Herrera Maria , Adams John D , Beckish Michael L , Bray Christopher C , Brown Timothy R , Cross Andrew W , Dew Timothy , Faucher Gregory K , Gurich Richard W , Lazarus David E , Millon S John , Moody M Christian , Palmer M Jason , Porter Scott E , Schaller Thomas M , Sridhar Michael S , Sanders John L , Rudisill L Edwin , Garitty Michael J , Poole Andrew S , Sims Michael L , Walker Clark M , Carlisle Robert , Hofer Erin A , Huggins Brandon , Hunter Michael , Marshall William , Ray Shea B , Smith Cory , Altman Kyle M , Quirion Julia C , Pichiotino Erin , Loeffler Markus F , Cole Austin A , Maltz Ethan J , Parker Wesley , Ramsey T Bennett , Burnikel Alex , Colello Michael , Stewart Russell , Wise Jeremy , Anderson Matthew , Eskew Joshua , Judkins Benjamin , Miller James M , Tanner Stephanie L , Snider Rebecca G , Townsend Christine E , Pham Kayla H , Martin Abigail , Robertson Emily , Bray Emily , Yoder Krystina , Conner Kelsey , Abbott Harper , Mormor Meir , Miclau Theodore , Matityahu Amir , McClellan R Trigg , Shearer David , Toogood Paul , Ding Anthony , Murali Jothi , El Naga Ashraf , Tangtiphaiboontana Jennifer , Belaye Tigist , Berhaneselase Eleni , Pokhvashchey Dmitry , Gary Joshua L , Warner Stephen J , Munz John W , Choo Andrew M , Achor Timothy S , Routt Milton L "Chip" , Kutzler Michael Kutzler , Boutte Sterling , Warth Ryan J , Hagen Jennifer E , Patrick Matthew , Vlasak Richard , Krupko Thomas , Talerico Michael , Horodyski Marybeth , Pazik Marissa , Lossada-Soto Elizabeth , Dehghan Niloofar , McKee Michael , Jones Clifford B , Sietsema Debra L , Williams Alyse , Dykes Tayler , Guerra-Farfan Ernesto , Thomas-Hernandez Jordi , Teixidor-Serra Jordi , Molero-Garcia Vicente , Selga-Marsa Jordi , Porcel-Vazquez Juan Antonio , Andres-Peiro Jose Vicente , Esteban-Feliu Ignacio , Vidal-Tarrason Nuria , Serracanta Jordi , Nuñez-Camarena Jorge , del Mar Villar-Casares Maria , Mestre-Torres Juame , Lalueza-Broto Pilar , Moreira-Borim Felipe , Garcia-Sanchez Yaiza , Marcano-Fernández Francesc , Martínez-Carreres Laia , Marti-Garin David , Serrano-Sanz Jorge , Sánchez-Fernández Joel , Sanz-Molero Matsuyama , Carballo Alejandro , Pelfort Xavier , Acerboni-Flores Francesc , Alavedra-Massana Anna , Anglada-Torres Neus , Berenguer Alexandre , Cámara-Cabrera Jaume , Caparros-García Ariadna , Fillat-Gomà Ferran , Fuentes-López Ruben , Garcia-Rodriguez Ramona , Gimeno-Calavia Nuria , Martínez-Álvarez Marta , Martínez-Grau Patricia , Pellejero-García Raúl , Ràfols-Perramon Ona , Manuel Peñalver Juan , Salomó Domènech Monica , Soler-Cano Albert , Velasco-Barrera Aldo , Yela-Verdú Christian , Bueno-Ruiz Mercedes , Sánchez-Palomino Estrella , Andriola Vito , Molina-Corbacho Matilde , Maldonado-Sotoca Yeray , Gasset-Teixidor Alfons , Blasco-Moreu Jorge , Fernández-Poch Núria , Rodoreda-Puigdemasa Josep , Verdaguer-Figuerola Arnau , Cueva-Sevieri Heber Enrique , Garcia-Gimenez Santiago , Obremsky William T , Jahangir Amir Alex , Sethi Manish , Boyce Robert , Stinner Daniel J , Mitchell Phillip , Trochez Karen , Rodriguez Elsa , Pritchett Charles , Hogan Natalie , Moreno A Fidel , Boulton Christina , Lowe Jason , Ruth John T , Askam Brad , Seach Andrea , Cruz Alejandro , Featherston Breanna , Carlson Robin , Romero Iliana , Zarif Isaac , Prayson Michael , Venkatarayappa Indresh , Horne Brandon , Jerele Jennifer , Clark Linda , Romeo Nicholas M , Vallier Heather A , Vergon Anna , Viskontas Darius G , Apostle Kelly L , Boyer Dory S , Moola Farhad O , Perey Bertrand H , Stone Trevor B , Lemke H Michael , Spicer Ella , Payne Krysten , Phelps Kevin , Bosse Michael , Karunakar Madhav , Kempton Laurence , Sims Stephen , Hsu Joseph , Seymour Rachel , Churchill Christine , Mayfield Ada , Sweeney Juliette , Hymes Robert A , Schwartzbach Cary C , Schulman Jeff E , Malekzadeh A Stephen , Holzman Michael A , Gaski Greg E , Wills Johnathan , Pilson Holly , Carroll Eben A , Halvorson Jason J , Babcock Sharon , Goodman J Brett , Holden Martha B , Williams Wendy , Hill Taylor , Brotherton Ariel , Higgins Thomas F , Haller Justin M , Rothberg David L , Olsen Zachary M , McGowan Abby V , Hill Sophia , Dauk Morgan K , Coe Marcus , Dwyer Kevin , Mullin Devin S , Chockbengboun Theresa A , DePalo Peter A , Heng Marilyn , Harris Mitchel B , Lhowe David W , Esposito John G , Alnasser Ahmad , Shannon Steven F , Scott Alesha N , Clinch Bobbi , Webber Becky , Beltran Michael J , Archdeacon Michael T , Sagi Henry Claude , Wyrick John D , Le Theodore Toan , Laughlin Richard T , Thomson Cameron G , Hasselfeld Kimberly , Lin Carol A , Vrahas Mark S , Moon Charles N , Little Milton T , Marecek Geoffrey S , Dubaclet Denice M , Scolaro John A , Learned James R , Lim Philip K , Demas Susan , Amirhekmat Arya , Dela Cruz Yan Marco , Bergin Patrick F , Russell George V , Graves Matthew L , Morellato John , McGee Sheketha L , Bhanat Eldrin L , Yener Ugur , Khanna Rajinder , Nehete Priyanka , Mehta Samir , Donehan Derek , Horan Annamarie , Dooley Mary , Potter David , VanDemark Robert , Seabold Kyle , Staudenmier Nicholas , Weaver Michael J , von Keudell Arvind G , Sagona Abigail E , Jaeblon Todd , Beer Robert , Bauer Brent , Meredith Sean , Talwar Sneh , Domes Christopher M , Gage Mark J , Reilly Rachel M , Paniagua Ariana , Depree JaNell 
Published: November 2022

Importance

Racial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.

Objective

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.

Design, Setting, and Participants

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.

Exposures

Patient-level and hospital-level race, ethnicity, and insurance status.

Main Outcomes and Measures

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.

Results

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; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79).

Conclusions and Relevance

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.