RESUMO
BACKGROUND: Total joint arthroplasty aims to improve quality of life and functional outcomes for all patients, primarily by reducing their pain. This goal requires clinical practice guidelines (CPGs) that equitably represent and enroll patients from all racial/ethnic groups. To our knowledge, there has been no formal evaluation of the racial/ethnic composition of the patient population in the studies that informed the leading CPGs on the topic of pain management after arthroplasty surgery. QUESTIONS/PURPOSES: Using papers included in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines and comparing them with US National census data, we asked: (1) What is the representation of racial/ethnic groups in randomized controlled trials compared with their representation in the US national population? (2) Is there a relationship between the reporting of racial/ethnic groups and year of data collection/publication, location of study, funding source, or guideline section? METHODS: Participant demographic data (study year published, study type, guideline section, year of data collection, study site, study funding, study size, gender, age, and race/ethnicity) were collected from articles cited by this guideline. Studies were included if they were full text, were primary research articles conducted primarily within the United States, and if they reported racial and ethnic characteristics of the participants. The exclusion criteria included duplicate articles, articles that included the same participant population (only the latest dated article was included), and the following article types: systematic reviews, nonsystematic reviews, terminology reports, professional guidelines, expert opinions, population-based studies, surgical trials, retrospective cohort observational studies, prospective cohort observational studies, cost-effectiveness studies, and meta-analyses. Eighty-two percent (223 of 271) of articles met inclusion criteria. Our original literature search yielded 27 papers reporting the race/ethnicity of participants, including 24 US-based studies and three studies conducted in other countries; only US-based studies were utilized as the focus of this study. We defined race/ethnicity reporting as the listing of participants' race or ethnicity in the body, tables, figures, or supplemental data of a study. National census information from 2000 to 2019 was then used to generate a representation quotient (RQ), which compared the representation of racial/ethnic groups within study populations to their respective demographic representation in the national population. An RQ value greater than 1 indicates an overrepresented group and an RQ value less than 1 indicates an underrepresented group, relative to the US population. Primary outcome measures of RQ value versus time of publication for each racial/ethnic group were evaluated with linear regression analysis, and race reporting and manuscript parameters were analyzed with chi-square analyses. RESULTS: Two US-based studies reported race and ethnicity independently. Among the 24 US-based studies reporting race/ethnicity, the overall RQ was 0.70 for Black participants, 0.09 for Hispanic participants, 0.1 for American Indian/Alaska Natives, 0 for Native Hawaiian/Pacific Islanders, 0.08 for Asian participants, and 1.37 for White participants, meaning White participants were overrepresented by 37%, Black participants were underrepresented by 30%, Hispanic participants were underrepresented by 91%, Asian participants were underrepresented by 92%, American Indian/Alaska Natives were 90% underrepresented, and Native Hawaiian Pacific Islanders were virtually not represented compared with the US national population. On chi-square analysis, there were differences between race/ethnicity reporting among studies with academic, industry, and dual-supported funding sources (χ2 = 7.449; p = 0.02). Differences were also found between race/ethnicity reporting among US-based and non-US-based studies (χ2 = 36.506; p < 0.001), with 93% (25 of 27) of US-based studies reporting race as opposed to only 7% (2 of 27) of non-US-based studies. Finally, there was no relationship between race/ethnicity reporting and the year of data collection or guideline section referenced. CONCLUSION: The 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines provide evidence-based recommendations that reflect the current standards in orthopaedic surgery, but the studies upon which they are based overwhelmingly underenroll and underreport racial/ethnic minorities relative to their proportions in the US population. As these factors impact analgesic administration, their continued neglect may perpetuate inequities in outcomes after TJA. CLINICAL RELEVANCE: Our study demonstrates that all non-White racial/ethnic groups were underrepresented relative to their proportion of the US population in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines, underscoring a weakness in the orthopaedic surgery evidence base and questioning the overall external validity and generalizability of these combined CPGs. An effort should be made to equitably enroll and report outcomes for all racial/ethnic groups in any updated CPGs.
RESUMO
BACKGROUND: One of the unforeseen impacts of the COVID-19 pandemic has been a decrease in athletes' confidence to return to their sport after mandates were lifted. Both physical and psychological effects have been implicated. This study aimed to measure the severity of these changes among a group of National Collegiate Athletic Association (NCAA) athletes. METHODS: A novel Readiness to Return to Sport Survey, based on the validated ACL-RSI survey, was distributed to Division 1 collegiate athletes. The survey evaluated the psychological readiness of each player to return to sport in the context of the COVID-19 pandemic, utilizing a 1-10 scale (1 = least confident and 10 = most confident). Numerical responses to each survey were summed to create a primary outcome score-an athlete's Return to Sport Readiness Score. Higher scores indicate higher levels of readiness to return to sport in the nearest coming season. RESULTS: Responses came from 68 athletes representing a variety of sports. Of those with an injury, 14 (82.35%) attributed their injury to changes in their training schedule due to COVID-19 restrictions, and the remaining three (17.65%) did not. Among all athletes, the mean return to sport readiness (RTS) score was 44 (SD 24.76). Those playing a winter sport had the lowest mean RTS score, 35 ± 23, and those playing a fall season sport had the highest mean score, 48 ± 25.97. Overall, competitive athletes on leave from the sport due to collegiate and Division 1 COVID-19 guidelines had lower reported mean RTS scores as compared to athletes outlined in many other anterior cruciate ligament return to sport after injury survey (ACL-RSI) studies. CONCLUSIONS: Overall, the athletes surveyed in our study reported much lower levels of readiness to return to sport in the context of COVID-19 than athletes surveyed in other studies, exhibiting COVID-19's unique impact on their confidence to return to their scheduled sport season. These differences may highlight the COVID-19 pandemic as a more severe detriment to returning to sport readiness among division-one athletes than recovering from injury alone. Given such an impact, more research is needed to elucidate the percentage of these athletes that returned to or abstained from their sport, as well as any motivating, facilitating, or detrimental factors in their choice.
