Issues in Ethics in Orthopaedic Surgery Following the COVID-19 Pandemic.

The COVID-19 pandemic has caused changes in health care as well as human suffering, and consideration of the principles of ethics can build a foundation to consider dilemmas that have arisen. Diversity, equity, and inclusion have become key issues. Simulation training and the related ethics of its application have taken on new meaning. Access to health care continues to evolve and will need further evaluation in the years following the COVID-19 pandemic.

The Importance of Perceived Barriers to Women Entering and Advancing in Orthopaedic Surgery in the US and Beyond.

BACKGROUND: Global perceptions of barriers to women in orthopaedics have not been assessed. The purpose of this study was to determine the importance of international barriers to women entering and advancing within orthopaedic surgery. METHODS: An anonymous, online survey was distributed to women medical students, trainees, and practicing surgeons via Women in Orthopaedics Worldwide, the "Women in Ortho" Facebook page, and individual programmes. Participants were asked to rate perceived barriers to (1) pursuing training and (2) career advancement on a scale of 1-5, with 5 being the most important and relative to other barriers. Descriptive statistics and univariate analyses were employed. RESULTS: The survey yielded 237 US (84.0%) and 45 international (16.0%) respondents. Per entering orthopaedic surgery, the most important barriers were male-dominated culture, lack of a strong women mentor, and lack of female representation at home institution. Compared with the US surgeons/trainees, international respondents cited greater societal disapproval (2.8 ± 1.2 vs. 3.4 ± 1.3, P = 0.01). Medical students assigned less importance to lack of exposure, more to lack of resources for creating competitive applications (P < 0.05). Regarding career advancement, lack of women leadership, family responsibilities, and gender-biased selection for promotion were the most important. International surgeons/trainees noted greater concern for societal disapproval (3.5 ± 1.5 vs. 2.6 ± 1.3, P = 0.003) and were more likely to rank sexual harassment in their top three (17.6 vs. 4.2%, P = 0.02). CONCLUSION: While notable differences exist, there is striking similarity across countries and position levels in perceived barriers to women entering and advancing in orthopaedic surgery. LEVEL OF EVIDENCE: III.

Medicaid Insurance is Associated With Decreased MRI Use for Ankle Sprains Compared With Private Insurance: A Retrospective Database Analysis.

BACKGROUND: Advanced imaging modalities are expensive, and access to advanced imaging services may vary by socioeconomic factors, creating the potential for unwarranted variations in care. Ankle sprains are a common injury for which variations in MRI use can occur, both via underuse of indicated MRIs (appropriate use) and overuse of nonindicated MRIs (inappropriate use). High-value, equitable healthcare would decrease inappropriate use and increase appropriate use of MRI for this common injury. It is unknown whether socioeconomic factors are associated with underuse of indicated MRIs and overuse of nonindicated MRIs for ankle sprains. QUESTIONS/PURPOSES: Using ankle sprains as a paradigm injury, given their high population incidence, we asked: (1) Does MRI use for ankle sprains vary by insurance type? (2) After controlling for relevant confounding variables, did patients who received an MRI have higher odds of undergoing ankle surgery? METHODS: Between 2011 and 2019, a total of 6,710,223 patients were entered into the PearlDiver Mariner Patient Records Database with a diagnosis of ankle sprain. We considered patients with continuous enrollment in the database for at least 1 year before and 2 years after the diagnosis as potentially eligible. Based on that, 68% (4,567,106) were eligible; a further 20% (1,372,478) were excluded because of age younger than 18 years, age at least 65 years with Medicaid insurance, or age < 65 years with Medicare insurance. Another 0.1% (9169) had incomplete data, leaving 47% (3,185,459) for analysis here. Patients with Medicaid insurance differed from patients with Medicare Advantage or private insurance with respect to age, gender, region, and comorbidity burden. The primary outcome was ankle MRI occurring within 12 months after diagnosis. The use of ankle surgery after MRI in each cohort was measured as a secondary outcome. We used multivariable logistic regression models to evaluate the association between insurance type and MRI use while adjusting for age, gender, region, and comorbidity burden. Separate multivariable regression models were created to evaluate the association between receiving an MRI and subsequent ankle surgery for each insurance type, adjusting for age, gender, region, and comorbidity burden. Within 12 months of an ankle sprain diagnosis, 1% (3522 of 339,457) of patients with Medicaid, 2% (44,793 of 2,627,288) of patients with private insurance, and 1% (1660 of 218,714) of patients with Medicare Advantage received an MRI. RESULTS: After controlling for age, gender, region, and comorbidity burden, patients with Medicaid had lower odds of receiving an MRI within 12 months after ankle sprain diagnosis than patients with private insurance (odds ratio 0.60 [95% confidence interval 0.57 to 0.62]; p < 0.001). Patients with Medicaid who received an MRI had higher adjusted odds of undergoing subsequent ankle surgery (OR 23 [95% CI 21 to 26]; p < 0.001) than patients with private insurance (OR 12.7 [95% CI 12 to 13]; p < 0.001). CONCLUSION: Although absolute MRI use was generally low, there was substantial relative variation by insurance type. Given the high incidence of ankle sprains in the general population, these relative differences can translate to tens of thousands of MRIs. Further studies are needed to evaluate the reasons for decreased appropriate MRI use in patients with Medicaid and overuse of MRI in patients with private insurance. The establishment of clinical practice guidelines by orthopaedic professional societies and more stringent gatekeeping for MRI use by health insurers could reduce unwarranted variations in MRI use. LEVEL OF EVIDENCE: Level III, prognostic study.

Are There Differences in Postoperative Opioid Prescribing Across Racial and Ethnic Groups? Assessment of an Academic Health System.

BACKGROUND: Previous studies have demonstrated racial disparities in opioid prescribing in emergency departments and after surgical procedures. Orthopaedic surgeons account for a large proportion of dispensed opioid prescriptions, yet there are few data investigating whether racial or ethnic disparities exist in opioid dispensing after orthopaedic procedures. QUESTIONS/PURPOSES: (1) Are Black, Hispanic or Latino, or Asian or Pacific Islander (PI) patients less likely than non-Hispanic White patients to receive an opioid prescription after an orthopaedic procedure in an academic United States health system? (2) Of the patients who do receive a postoperative opioid prescription, do Black, Hispanic or Latino, or Asian or PI patients receive a lower analgesic dose than non-Hispanic White patients when analyzed by type of procedure performed? METHODS: Between January 2017 and March 2021, 60,782 patients underwent an orthopaedic surgical procedure at one of the six Penn Medicine healthcare system hospitals. Of these patients, we considered patients who had not been prescribed an opioid within 1 year eligible for the study, resulting in 61% (36,854) of patients. A total of 40% (24,106) of patients were excluded because they did not undergo one of the top eight most-common orthopaedic procedures studied or their procedure was not performed by a Penn Medicine faculty member. Missing data consisted of 382 patients who had no race or ethnicity listed in their record or declined to provide a race or ethnicity; these patients were excluded. This left 12,366 patients for analysis. Sixty-five percent (8076) of patients identified as non-Hispanic White, 27% (3289) identified as Black, 3% (372) identified as Hispanic or Latino, 3% (318) identified as Asian or PI, and 3% (311) identified as another race ("other"). Prescription dosages were converted to total morphine milligram equivalents for analysis. Statistical differences in receipt of a postoperative opioid prescription were assessed with multivariate logistic regression models within procedure, adjusted for age, gender, and type of healthcare insurance. Kruskal-Wallis tests were used to assess for differences in the total morphine milligram equivalent dosage of the prescription, stratified by procedure. RESULTS: Almost all patients (95% [11,770 of 12,366]) received an opioid prescription. After risk adjustment, we found no differences in the odds of Black (odds ratio 0.94 [95% confidence interval 0.78 to 1.15]; p = 0.68), Hispanic or Latino (OR 0.75 [95% CI 0.47 to 1.20]; p = 0.18), Asian or PI (OR 1.00 [95% CI 0.58 to 1.74]; p = 0.96), or other-race patients (OR 1.33 [95% CI 0.72 to 2.47]; p = 0.26) receiving a postoperative opioid prescription compared with non-Hispanic White patients. There were no race or ethnicity differences in the median morphine milligram equivalent dose of postoperative opioid analgesics prescribed (p > 0.1 for all eight procedures) based on procedure. CONCLUSION: In this academic health system, we did not find any differences in opioid prescribing after common orthopaedic procedures by patient race or ethnicity. A potential explanation is the use of surgical pathways in our orthopaedic department. Formal standardized opioid prescribing guidelines may reduce variability in opioid prescribing. LEVEL OF EVIDENCE: Level III, therapeutic study.

Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts.

BACKGROUND: Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients. METHODS: Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement). RESULTS: Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients. CONCLUSIONS: Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients' expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.

COVID-19 and the orthopaedic surgeon: who gets redeployed?

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions about physicians' obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm.

Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients?

BACKGROUND: Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use. QUESTIONS/PURPOSES: (1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA? METHODS: In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05. RESULTS: THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325). CONCLUSION: Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area. LEVEL OF EVIDENCE: Level III, therapeutic study.

How Do Medical Students Perceive Diversity in Orthopaedic Surgery, and How Do Their Perceptions Change After an Orthopaedic Clinical Rotation?

BACKGROUND: A diverse physician workforce improves the quality of care for all patients, and there is a need for greater diversity in orthopaedic surgery. It is important that medical students of diverse backgrounds be encouraged to pursue the specialty, but to do so, we must understand students' perceptions of diversity and inclusion in orthopaedics. We also currently lack knowledge about how participation in an orthopaedic clinical rotation might influence these perceptions. QUESTIONS/PURPOSES: (1) How do the perceptions of diversity and inclusion in orthopaedic surgery compare among medical students of different gender identities, races or ethnicities, and sexual orientations? (2) How do perceptions change after an orthopaedic clinical rotation among members of demographic groups who are not the majority in orthopaedics (that is, cis-gender women, underrepresented racial minorities, other racial minorities, and nonheterosexual people)? METHODS: We surveyed students from 27 US medical schools who had completed orthopaedic rotations. We asked about their demographic characteristics, rotation experience, perceptions of diversity and inclusion in orthopaedics, and personal views on specialty choice. Questions were derived from diversity, equity, and inclusion climate surveys used at major academic institutions. Cis-gender men and cis-gender women were defined as those who self-identified their gender as men or women, respectively, and were not transgender. Forty-five percent (59 of 131) of respondents were cis-men and 53% (70 of 131) were cis-women; 49% (64 of 131) were white, 20% (26 of 131) were of underrepresented racial minorities, and 31% (41 of 131) were of other races. Eighty-five percent (112 of 131) of respondents were heterosexual and 15% (19 of 131) reported having another sexual orientation. We compared prerotation and postrotation perceptions of diversity and inclusion between majority and nonmajority demographic groups for each demographic domain (for example, cis-men versus cis-women). We also compared prerotation to postrotation perceptions within each nonmajority demographic group. To identify potential confounding variables, we performed univariate analysis to compare student and rotation characteristics across the demographic groups, assessed using an alpha of 0.05. No potential confounders were identified. Statistical significance was assessed at a Bonferroni-adjusted alpha of 0.0125. Our estimated response percentage was 26%. To determine limitations of nonresponse bias, we compared all early versus late responders and found that for three survey questions, late responders had a more favorable perception of diversity in orthopaedic surgery, whereas for most questions, there was no difference. RESULTS: Before rotation, cis-women had lower agreement that diversity and inclusion are part of orthopaedic culture (mean score 0.96 ± 0.75) compared with cis-men (1.4 ± 1.1) (mean difference 0.48 [95% confidence interval 0.16 to 0.81]; p = 0.004), viewed orthopaedic surgery as less diverse (cis-women 0.71 ± 0.73 versus cis-men 1.2 ± 0.92; mean difference 0.49 [95% CI 0.20 to 0.78]; p = 0.001) and more sexist (cis-women 1.3 ± 0.92 versus cis-men 1.9 ± 1.2; mean difference 0.61 [95% CI 0.23 to 0.99]; p = 0.002), believed they would have to work harder than others to be valued equally (cis-women 2.8 ± 1.0 versus cis-men 1.9 ± 1.3; mean difference 0.87 [95% CI 0.45 to 1.3]; p < 0.001), and were less likely to pursue orthopaedic surgery (cis-women 1.4 ± 1.4 versus cis-men 2.6 ± 1.1; mean difference 1.2 [95% CI 0.76 to 1.6]; p < 0.001). Before rotation, underrepresented minorities had less agreement that diversity and inclusion are part of orthopaedic surgery culture (0.73 ± 0.72) compared with white students (1.5 ± 0.97) (mean difference 0.72 [95% CI 0.35 to 1.1]; p < 0.001). Many of these differences between nonmajority and majority demographic groups ceased to exist after rotation. Compared with their own prerotation beliefs, after rotation, cis-women believed more that diversity and inclusion are part of orthopaedic surgery culture (prerotation mean score 0.96 ± 0.75 versus postrotation mean score 1.2 ± 0.96; mean difference 0.60 [95% CI 0.22 to 0.98]; p = 0.002) and that orthopaedic surgery is friendlier (prerotation 2.3 ± 1.2 versus postrotation 2.6 ± 1.1; mean difference 0.41 [95% CI 0.14 to 0.69]; p = 0.004), more diverse (prerotation 0.71 ± 0.73 versus postrotation 1.0 ± 0.89; mean difference 0.28 [95% CI 0.08 to 0.49]; p = 0.007), less sexist (prerotation 1.3 ± 0.92 versus postrotation 1.9 ± 1.0; mean difference 0.63 [95% CI 0.40 to 0.85]; p < 0.001), less homophobic (prerotation 2.1 ± 1.0 versus postrotation 2.4 ± 0.97; mean difference 0.27 [95% CI 0.062 to 0.47]; p = 0.011), and less racist (prerotation 2.3 ± 1.1 versus postrotation 2.5 ± 1.1; mean difference 0.28 [95% CI 0.099 to 0.47]; p = 0.003). Compared with before rotation, after rotation cis-women believed less that they would have to work harder than others to be valued equally on the rotation (prerotation 2.8 ± 1.0 versus postrotation 2.5 ± 1.0; mean difference 0.31 [95% CI 0.12 to 0.50]; p = 0.002), as did nonheterosexual students (prerotation 2.4 ± 1.4 versus postrotation 1.8 ± 1.3; mean difference 0.56 [95% 0.21 to 0.91]; p = 0.004). Underrepresented minority students saw orthopaedic surgery as less sexist after rotation compared with before rotation (prerotation 1.5 ± 1.1 versus postrotation 2.0 ± 1.1; mean difference 0.52 [95% CI 0.16 to 0.89]; p = 0.007). CONCLUSION: Even with an estimated 26% response percentage, we found that medical students of demographic backgrounds who are not the majority in orthopaedics generally perceived that orthopaedic surgery is less diverse and inclusive than do their counterparts in majority groups, but these views often change after a clinical orthopaedic rotation. CLINICAL RELEVANCE: These perceptions may be a barrier to diversification of the pool of medical student applicants to orthopaedics. However, participation in an orthopaedic surgery rotation is associated with mitigation of many of these negative perceptions among diverse students. Medical schools have a responsibility to develop a diverse workforce, and given our findings, schools should promote participation in a clinical orthopaedic rotation. Residency programs and orthopaedic organizations can also increase exposure to the field through the rotation and other means. Doing so may ultimately diversify the orthopaedic surgeon workforce and improve care for all orthopaedic patients.

Are There Gender-based Differences in Language in Letters of Recommendation to an Orthopaedic Surgery Residency Program?

BACKGROUND: Letters of recommendation are considered one of the most important factors for whether an applicant is selected for an interview for orthopaedic surgery residency programs. Language differences in letters describing men versus women candidates may create differential perceptions by gender. Given the gender imbalance in orthopaedic surgery, we sought to determine whether there are differences in the language of letters of recommendation by applicant gender. QUESTIONS/PURPOSES: (1) Are there differences in word count and word categories in letters of recommendation describing women and men applicants, regardless of author gender? (2) Is author gender associated with word category differences in letters of recommendation? (3) Do authors of different academic rank use different words to describe women versus men applicants? METHODS: Using a linguistic analysis in a retrospective study, we analyzed all letters of recommendation (2834 letters) written for all 738 applicants with completed Electronic Residency Application Service applications submitted to the Johns Hopkins Orthopaedic Surgery Residency program during the 2018 to 2019 cycle to determine differences in word category use among applicants by gender, authors by gender, and authors by academic rank. Thirty nine validated word categories from the Linguistic Inquiry and Word Count dictionary along with seven additional word categories from previous publications were used in this analysis. The occurrence of words in each word category was divided by the number of words in the letter to obtain a word frequency for each letter. We calculated the mean word category frequency across all letters and analyzed means using non-parametric tests. For comparison of two groups, a p value threshold of 0.05 was used. For comparison of multiple groups, the Bonferroni correction was used to calculate an adjusted p value (p = 0.00058). RESULTS: Letters of recommendation for women applicants were slightly longer compared with those for men applicants (366 ± 188 versus 339 ± 199 words; p = 0.003). When comparing word category differences by applicant gender, letters for women applicants had slightly more "achieve" words (0.036 ± 0.015 versus 0.035 ± 0.018; p < 0.0001). Letters for men had more use of their first name (0.016 ± 0.013 versus 0.014 ± 0.009; p < 0.0001), and more "young" words (0.001 ± 0.003 versus 0.000 ± 0.001; p < 0.0001) than letters for women applicants. These differences were very small as each 0.001 difference in mean word frequency was equivalent to one more additional word from the word category appearing when comparing three letters for women to three letters for men. For differences in letters by author gender, there were no word category differences between men and women authors. Finally, when looking at author academic rank, letters for men applicants written by professors had slightly more "research" terms (0.011 ± 0.010) than letters written by associate professors (0.010 ± 0.010) or faculty of other rank (0.009 ± 0.011; p < 0.0001), a finding not observed in letters written for women. CONCLUSIONS: Although there were some minor differences favoring women, language in letters of recommendation to an academic orthopaedic surgery residency program were overall similar between men and women applicants. CLINICAL RELEVANCE: Given the similarity in language between men and women applicants, increasing women applicants may be a more important factor in addressing the gender gap in orthopaedics.

Eligibility Criteria for Lower Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities.

BACKGROUND: Cost-containment strategies may discourage hospitals from performing surgery for patients with preexisting risk factors such as those with high body mass index (BMI), those with high hemoglobin A1c (HbA1c), or those who smoke cigarettes. Because these risk factors may not appear in equal proportions across the population, using these risk factors as inflexible eligibility criteria for lower extremity joint arthroplasty may exacerbate existing racial-ethnic, gender, and socioeconomic disparities pertaining to access to an operation that can improve health and quality of life. However, any effects on such disparities have not yet been quantified nor have the groups been identified that may be most affected by inflexible eligibility criteria. QUESTIONS/PURPOSES: Does the use of inflexible eligibility criteria related to (1) BMI; (2) HbA1c level; and (3) smoking status potentially decrease the odds of lower extremity joint arthroplasty eligibility for members of racial-ethnic minority groups, women, and those of lower socioeconomic status more than it does for non-Hispanic whites, men, and those of higher socioeconomic status? METHODS: We pooled data from 21,294 adults aged ≥ 50 years from the 1999-2014 National Health and Nutrition Examination Survey (NHANES). NHANES is a nationally administered series of surveys that assess the health and nutritional status of the US population and collect information on many risk factors for diseases. NHANES is uniquely suited to examine our study questions because it includes data from physical examinations and laboratory assessments as well as comprehensive questionnaires, and it is nationally representative. We determined the odds of lower extremity arthroplasty eligibility by running separate multivariable logistic regressions for each criterion (that is, for each dependent variable): (1) BMI < 35 kg/m; (2) BMI < 40 kg/m; (3) HbA1c < 8%; and (4) current nonsmoker status. Independent variables of interest were race-ethnicity, gender, educational level, and annual household income. Each model included all independent variables of interest, age, and survey year. RESULTS: The BMI < 35-kg/m criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks compared with non-Hispanic whites (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.55-0.70; p < 0.001), women versus men (OR, 0.61; 95% CI, 0.55-0.69; p < 0.001), individuals of lower socioeconomic status versus those of higher socioeconomic status (annual household income < USD 45,000 versus ≥ USD 45,000 [OR, 0.81; 95% CI, 0.71-0.93; p = 0.002], and those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.66; 95% CI, 0.57-0.77; p < 0.001). The HbA1c < 8% criterion resulted in lower arthroplasty eligibility for non-Hispanic blacks (OR, 0.44; 95% CI, 0.37-0.53; p < 0.001) and Hispanics (OR, 0.41; 95% CI, 0.33-0.51; p < 0.001) versus non-Hispanic whites, for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.73; 95% CI, 0.56-0.94; p = 0.015), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.58; 95% CI, 0.44-0.77; p < 0.001). Excluding smokers resulted in lower arthroplasty eligibility for non-Hispanic blacks versus non-Hispanic whites (OR, 0.84; 95% CI, 0.73-0.97; p = 0.019), for individuals of lower socioeconomic status versus those of higher socioeconomic status (OR, 0.53; 95% CI, 0.47-0.61; p < 0.001), and for those with a high school degree or less versus those with a degree beyond a high school degree (OR, 0.29; 95% CI, 0.24-0.35; p < 0.001). CONCLUSIONS: Payment structures and clinical decision-making algorithms that set inflexible cutoffs with respect to BMI, HbA1c, and smoking status disproportionately discourage performing lower extremity arthroplasty for non-Hispanic blacks and individuals of lower socioeconomic status. We do not advocate performing elective surgery for patients with multiple, uncontrolled medical comorbidities. However, ample evidence suggests that many patients whose BMI values are > 35 kg/m (or even > 40 kg/m) may be reasonable candidates for arthroplasty surgery, and BMI is not an easily modifiable risk factor for many patients. We discourage across-the-board cutoff parameters in these domains because such cutoffs will worsen current racial-ethnic, gender-based, and socioeconomic disparities and limit access to an operation that can improve quality of life. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

The Ethics of Bundled Payments in Total Joint Replacement: "Cherry Picking" and "Lemon Dropping."

The Centers for Medicare & Medicaid Services has initiated bundled payments for hip and knee total joint replacement in an effort to decrease healthcare costs and increase quality of care. The ethical implications of this program have not been studied. This article considers the ethics of patient selection to improve outcomes; specifically, screening patients by body mass index to determine eligibility for total joint replacement. I argue that this type of screening is not ethically defensible, and that the bundled payment program as structured is likely to lead to unfair restrictions on who receives total joint replacements.

The Ethics of Bundled Payments in Total Joint Replacement: "Cherry Picking" and "Lemon Dropping".

The Centers for Medicare and Medicaid Services has initiated bundled payments for hip and knee total joint replacement in an effort to decrease healthcare costs and increase quality of care. The ethical implications of this program have not been studied. This article considers the ethics of patient selection to improve outcomes; specifically, screening patients by body mass index to determine eligibility for total joint replacement. I argue that this type of screening is not ethically defensible, and that the bundled payment program as structured is likely to lead to unfair restrictions on who receives total joint replacements.