title: Persisting Racial Disparities in Total Shoulder Arthroplasty Utilization and Outcomes.
abstract: OBJECTIVE
  The purpose was to study whether racial disparities in total shoulder arthroplasty (TSA) utilization and outcomes have declined over time.
  
  
  METHODS
  We used the US Nationwide Inpatient Sample from 1998 to 2011.We used chi-squared test to compare characteristics, Cochran-Armitage test to compare utilization rates, and Cochran-Armitage test and logistic regression to compare time-trends in outcomes by race.
  
  
  RESULTS
  From 1998 to 2011, 176,141 Whites and 7694 Blacks underwent TSA. Compared to Whites, Blacks who underwent TSA were younger (69.1 vs. 64.2 years;p<0.0001), more likely to be female (54.9 vs. 71.0 %;p<0.0001), and have rheumatoid arthritis or avascular necrosis as the underlying diagnosis (1.7 vs. 3.0%and 1.7 vs. 6.1 %;p<0.0001 for both) and a Deyo-Charlson index of 2 or higher (8.5 vs. 16.7 %;p<0.0001). Compared to Whites, Blacks had much lower TSA utilization rate/100,000 in 1998 (2.97 vs. 0.83;p<0.0001) and in 2011 (12.27 vs. 3.33;p<0.0001); racial disparities increased from 1998 to 2011 (p<0.0001). A higher proportion of Blacks than Whites had a hospital stay greater than median in 1998-2000, 62 vs. 51.4 % (p=0.02), and in 2009-2011, 34.4 vs. 27.3 % (p<0.0001); disparities did not change over time (p=0.31). These disparities in utilization were borderline significant in adjusted analyses. There were no racial differences in proportion discharged to inpatient medical facility in 1998-2000, 15.2 vs. 15.0 % (p=0.95), and in 2009-2011, 12.3 vs. 11.1%(p=0.37), respectively.
  
  
  CONCLUSIONS
  We found increasing racial disparities in TSA utilization. Some disparities in outcomes exist as well. Patients, surgeons, and policy-makes should be aware of these findings and take action to reduce racial disparities.
authors.affiliation: Birmingham VA Medical Center, Birmingham, AL, USA ; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294, USA ; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Jasvinder A
authors.initials: JA
authors.lastname: Singh
authors.affiliation: Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294, USA.
authors.forename: Rekha
authors.initials: R
authors.lastname: Ramachandran
keywords: Discharge; Hospital stay; Mortality; Outcomes; Race; TSA; Time-trends; Total shoulder arthroplasty; Utilization