The COVID-19 pandemic has shown a spotlight on disparities in the U.S. healthcare system. But the issues are longstanding, and — as one large study illustrates — extend into a common elective surgery.
Researchers found that when hip replacement surgery is done at a "safety net" hospital designed to serve the poor and uninsured, patients' risks are higher. Of more than 500,000 Americans who had the surgery, those at safety net hospitals were 11% more likely to have postoperative complications, like infections or heart problems.
And while few patients died, patients at safety net hospitals had more than a third greater risk.
In the United States, safety net hospitals are obligated — by mandate or mission — to treat people regardless of their ability to pay. So, they typically have a large share of patients who are low-income, minority and either uninsured or on Medicaid.
A number of studies have found that Black, Latino and Medicaid patients have more complications after joint replacement surgery, versus white and privately insured patients.
But do hospitals, themselves, play a role in those disparities? The answer is "a definite yes," said Dr. Kevin Bozic, chair of surgery and perioperative care at the University of Texas at Austin Dell Medical School.
Bozic, who was not involved in the research, said it adds to evidence that differences in hospital care are part of the problem.
"Safety net hospitals do the best they can with the resources they have," he said.
But because they are operating on slim margins, Bozic said, they cannot make investments that more profitable hospitals can. That includes the extra help more vulnerable patients often need — including social workers, transportation and nutritional support.
The irony is that hospitals with the most patients in need are the least likely to have social support resources, according to Bozic.
The findings, published in the journal Regional Anesthesia & Pain Medicine, are based on discharge records from hospitals in five U.S. states. The patients underwent hip replacement between 2007 and 2014.
It's a period well before the COVID-19 pandemic, which has laid bare the disparities in U.S. health care.
Now, with increased attention on those longstanding issues, the momentum may be in place to address them, said Dr. Robert White.
White, who led the study, is an anesthesiologist at New York Presbyterian Hospital-Weill Cornell Medicine in New York City.
He said his research cannot pinpoint the reasons safety net hospitals might fall short. But like Bozic, he pointed to lack of resources as a likely factor.
Overall, White's team found, patients at safety net hospitals had an in-hospital death rate of 0.2%, versus 0.1% at hospitals with relatively few Medicaid and uninsured patients.
The researchers weighed other factors that could explain the difference — including patients' medical conditions — and found that safety net hospitals were still an independent factor: Patients there were 30% to 38% more likely to die, relative to those at other hospitals.
In addition, their rate of infection was higher (1.6% versus 1.4%), as was their rate of heart-related complications (1.5%, versus 1.4%).
Dr. Charles Nelson is chief of the joint replacement service at Penn Medicine in Philadelphia. Reviewing the study, he said that safety net hospitals face a big challenge: They generally have "more complex" patients who may be in poorer health, have less social support and may more often need hip replacement due to a fracture, rather than to treat painful arthritis.
Adding to the financial strain, Nelson pointed out, safety net hospitals are more affected by Medicare rules that penalize hospitals for having high readmission rates.
Racial disparities in joint replacement outcomes are "multi-factorial," Nelson said, and it's difficult to separate the reasons from each other.
Patients on Medicaid may be limited in how much hospital-shopping they can do before elective hip surgery. But Nelson recommended asking some basic questions before deciding on a hospital: How many procedures does the hospital and surgeon do each year? And what is the postoperative complication rate?