National Racial and Sex Disparities in Primary Total Hip and Knee Arthroplasty Utilization: A Nationwide Analysis, 2016-2021.

Total joint arthroplasty (TJA) is one of the most commonly performed elective surgical procedures in the United States. Prior studies up to 2015 have found racial disparities in utilization to exist despite a higher osteoarthritis burden among Black patients. The intersection of race and sex disparities in TJA utilization is poorly understood. Using the 2016-2021 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures for degenerative joint disease were identified. Age-adjusted Black and White utilization rates, using U.S. Census data, were stratified by sex. Patient, hospital, and outcome variables were compared, and the temporal inpatient trends were analyzed using linear regression models adjusted for the COVID-19 pandemic. Of the 4,067,950 patients, Black patients were younger, more likely to be in the lowest income quartile, have Medicaid insurance, and have undergone surgery at urban teaching hospitals than White patients (all p < 0.001). They had longer hospital stays and higher morbidity (p < 0.001). In 2016, THA utilization was 9.8 per 10,000 for White individuals compared with 4.3 for Black individuals; this disparity increased over the study period (p = 0.01). White women had the highest utilization rates, and Black men had the lowest. Disparities between White and Black women in THA utilization were found to increase (p = 0.03), whereas disparities between White and Black men remained consistent. For TKA, utilization was 19.1 per 10,000 for White individuals compared with 9.4 for Black individuals in 2016. White-Black, White-Black men, and White-Black women disparities in utilization remained consistent over the study period. From 2016 to 2021, racial disparities in inpatient TKA persisted, while disparities in inpatient THA utilization worsened, with pronounced differences found at the intersection of race and sex. These findings highlight the need for targeted, equity-focused interventions to improve access to TJA.