Access to Orthopaedic Surgical Care: Demographic Impacts on Utilization Rates of Hip and Knee Arthroplasty

The positive impact of knee and hip arthroplasty on postoperative pain and function is well documented1-3. Recent interest and research into the lack of access to hip and knee arthroplasty in minority populations has been revealing1,2. The purpose of our study was to examine access to hip and knee arthroplasty, across Canada by province (excluding territories and Quebec) for racially visible individuals (RV) compared non-racially visible individuals (non-RV). Additionally, we set out to compare national knee and hip arthroplasty rates in people of African Descent (AD) to that of the general population (non-AD). The study population was identified from the 2016 Canadian long-form census which was completed by 25% of all households. Sample weights were utilized to ensure results were representative of the entire population. Self-reported ethnicity was used to identify RV and AD. Health utilization data from the Canadian Institutes for Health Information Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) were linked to the census data. Procedures of hip and knee arthroplasty (including revisions) were identified in the health utilization data using the Canadian Classification of Health Intervention codes. First Nations populations were excluded from the study as data collection was not compliant with the First Nations OCAP Principles. Multivariate logistic regression was undertaken to compare rates between groups controlling for confounders which included age, sex, co-morbidities, province, immigrant status, language, education, income, and geographic location. The Chi-squared statistic was used to test for significant differences at a 95% confidence level. Results showed crude rates for both procedures were lower for both RVs and ADs across all provinces. Multivariate analysis showed an adjusted odds ratio (OR) of 0.264 [CI 0.253-0.276] for hip arthroplasty suggesting RVs were 74% less likely to undergo the procedure (P < 0.001). The adjusted OR for knee arthroplasty was 1.07[CI 1.04-1.10] in favor of RVs (P < 0.001). The probability of having a hip arthroplasty was 50% (OR 0.508) lower for those of AD after controlling for confounders (P < 0.001). For knee arthroplasty, the AD population was 15% less likely to have the procedure (OR 0.856, P < 0001). Disparities in access to hip and knee arthroplasty exist for the AD population. Among RVs there is a significant disparity in access to hip arthroplasty. Lower rates observed for RVs and ADs are consistent across provinces. Policymakers and clinicians should explore the reasons for disparities as the trend towards more diverse ethnicities continues to grow across the country.