Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database.

BACKGROUND: Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear. QUESTIONS/PURPOSES: (1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA? METHODS: Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race. RESULTS: After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001). CONCLUSION: These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patient Perceptions of the Safety of Outpatient Total Knee Arthroplasty.

BACKGROUND: Outpatient total joint arthroplasty is considered safe in a selected group of patients, based primarily on complications. However, patient perception of the safety of outpatient total joint arthroplasty is unknown. This study assesses patient perceptions of the potential benefits of and barriers to outpatient total knee arthroplasty among a cohort of patients who have recently undergone the procedure. METHODS: Patients who underwent unilateral primary total knee arthroplasty between March 1, 2017, and September 30, 2017 at our institution were given a questionnaire, in which they were asked about prior knowledge regarding outpatient total knee arthroplasty, their perceived ability to undergo the procedure as an outpatient, and their perceived risks and benefits to outpatient surgery. RESULTS: Three hundred forty-six patients completed the survey. Over 70% of patients did not think that they would be able to undergo total knee arthroplasty as an outpatient. Their primary concerns were pain, being able to go to the bathroom, and falls. CONCLUSIONS: Patients in this study largely would not feel safe undergoing total knee arthroplasty on an outpatient basis. Payers should not only take into account existing literature but also the concerns and perceived needs of patients, before encouraging widespread implementation of outpatient total knee arthroplasty.

The Impact of Hospital Volume on Racial Differences in Complications, Readmissions, and Emergency Department Visits Following Total Joint Arthroplasty.

BACKGROUND: Minority patients are at higher risk for complications and readmissions after total hip and knee arthroplasty. They are also more likely to undergo joint replacement in lower volume centers, which is associated with poorer outcomes. It is unknown whether these disparities simply reflect disproportionate use of lower volume centers. This study evaluates the impact of hospital volume on racial differences in outcomes following joint replacement. METHODS: Patients who underwent total hip or knee arthroplasty between 2006 and 2013 in New York and Florida were identified through the Healthcare Cost and Utilization Project State Inpatient Databases. Complications, readmissions, and emergency department (ED) visits within 90 days were compared by hospital volume. Relative risks were calculated with generalized estimating equations for risk factors associated with adverse outcomes. RESULTS: Race/ethnicity was not associated with readmission following hip replacement. Black race was associated with readmission following knee replacement (relative risk [RR] 1.16). Black race was associated with ED visits following hip replacement (RR 1.29) and knee replacement (RR 1.33). Hispanic ethnicity was associated with ED visits following knee replacement (RR 1.15), but not hip replacement. These associations did not change after adjusting for hospital volume. CONCLUSION: Adjusting for hospital volume does not alter the risk of readmissions and ED use associated with minority race/ethnicity, suggesting that hospital volume alone may be insufficient to explain racial differences in outcome.

Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial.

BACKGROUND: Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES: We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS: Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS: Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS: Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

What is the prognosis of revision total hip arthroplasty in patients 55 years and younger?

BACKGROUND: Revision THAs are expected to increase; however, few studies have characterized the prognosis of revision THAs in younger patients. QUESTIONS/PURPOSES: We performed a case-control study to evaluate intermediate-term survivorship, complications, and hip and activity scores after revision THAs in patients 55 years and younger, compared these outcomes with the results of primary THAs in a matched patient population, and evaluated risk factors for failed revisions. METHODS: Ninety-three patients (103 hips) had a minimum of 4 years after revision THA, died, or had rerevision surgery. They were matched with 98 patients (103 hips) with primary THAs. Survivorship, complications, and clinical outcomes were compared between the groups using t-tests. Risk factors for failure also were assessed with chi-square analysis. RESULTS: At mean followup of 6.7 years, 71 revision THAs (69%) survived, compared with 102 (99%) primary THAs (odds ratio [OR], 45.9; 95% CI, 16.5-128.4; p < 0.001). Complications occurred in 29% of the revision group and 6% of the primary group (OR, 6.64; 95% CI, 4.14-10.67; p < 0.001). After revision THA, the average improvement in Harris hip score was 19.2 compared with 34.4 after primary THA (p < 0.001). The UCLA activity score improved by an average of 0.87 after revision compared with 2.36 after primary THA (p < 0.001). Conventional polyethylene was associated with failure after revision THA (OR, 2.98; 95% CI, 1.87-4.76; p = 0.004). CONCLUSIONS: At intermediate-term followup, young patients undergoing revision THAs had markedly higher failure and complication rates and more modest clinical improvements compared with patients in a matched cohort who had primary THAs. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Has total hip arthroplasty in patients 30 years or younger improved? A systematic review.

BACKGROUND: The evolution of total hip arthroplasty (THA) generally has led to improved clinical results. However, THA in very young patients historically has been associated with lower survivorship, and it is unclear whether this, or results pertaining to pain and function, has improved with contemporary THA. QUESTIONS/PURPOSES: We performed a systematic review of the English literature on THA in patients 30 years of age and younger to assess changes in (1) indications; (2) implant selection; (3) clinical and radiographic outcomes; and (4) survivorship when comparing contemporary and historical reports. METHODS: Multiple databases were searched for articles published between 1965 and 2011 that reported clinical and radiographic outcomes of THA in patients 30 years and younger. Sixteen retrospective case series were identified. Surgical indications, implant selection, clinical and radiographic outcomes, and survivorship of patients undergoing THAs before 1988 were compared with those performed in 1988 and after. RESULTS: Reported THAs performed more recently were less likely to be performed for juvenile rheumatoid arthritis than earlier procedures. Cementless fixation became more prevalent in later years. Although clinical outcome scores remained constant, aseptic loosening and revision rates decreased substantially with more contemporary procedures. CONCLUSIONS: This review of the literature demonstrates an improvement in radiographic outcomes and survivorship of THA, but no significant differences in pain and function scores, in very young patients treated over the past two decades when compared with historical controls.

Immediate complications following hip and knee arthroplasty: does race matter?

Black race has been associated with a higher rate of complications following total joint arthroplasty, such as infection, deep vein thrombosis, pulmonary embolism, and death. We hypothesized that there would be no significant association between black race and adverse outcome when medical conditions were adjusted for. Data on 585,269 patients from the Nationwide Inpatient Samples were assessed by multivariable logistic regression analysis. Black race was significantly associated with postoperative complication and death. Comorbidities do not account for racial differences in adverse events. Black race was an independent predictive factor for increased complications and death following hip and knee arthroplasty.

Readmission following total knee arthroplasty: venous thromboembolism as a "never event" is a counterproductive misnomer.

A national quality improvement initiative identifies certain avoidable complications as "never events," and includes venous thromboembolism (VTE). This study examines the incidence and cost of VTE following total knee arthroplasty (TKA) compared to other causes of readmission and the degree to which VTE was preventable. One hundred twenty-one readmissions (105 patients) were reviewed to determine the reason for readmission, cost, and compliance with SCIP VTE prophylaxis guidelines. The most common reasons for readmission were limited motion (18.2%), wound complication (14%), surgical site infection (9.9%), and bleeding (9.9%). VTE was less common (3.3%), and all occurred despite adequate prophylaxis. The cost of bleeding, wound complications, infection, and limited motion each exceeded the cost of VTE. These results challenge the identification of VTE as a "never event."

Effect of Lawsuits on Professional Well-Being and Medical Error Rates Among Orthopaedic Surgeons.

INTRODUCTION: Orthopaedic surgery is one of the most cited specialties among legal claims. Malpractice lawsuits are financially burdensome, increase defensive practices, and incur a notable emotional toll on defendants. We sought to determine the effect of malpractice lawsuits on professional well-being and self-reported medical errors among orthopaedic surgeons. METHODS: We surveyed 305 members of the American Orthopaedic Association to collect information on experiences with medical malpractice lawsuits, demographic and practice characteristics, professional well-being on the Professional Fulfillment Index, and self-reported medical errors. Multivariable logistic regression identified predictors of malpractice lawsuits, professional well-being, and self-reported medical errors. RESULTS: Seventy-three percent (224 of 305) respondents had been involved in a medical malpractice lawsuit. The odds of experiencing a malpractice lawsuit increased by seven percent with each year in practice (OR = 1.07, 95% CI: 1.04 to 1.10, P < 0.001) and with specialization in spine surgery. Respondents with a lawsuit in 2 years before the survey reported comparable professional well-being and medical error rates with those without a lawsuit. However, compared with respondents without a lawsuit, respondents with a lawsuit more than 2 years in the past were less likely to report burnout (OR = 0.43, 95% CI: 0.20 to 0.90, P = 0.03) and more likely to report a medical error in the past year, which resulted in patient harm (OR = 3.51, 95% CI: 1.39 to 8.91, P = 0.008). DISCUSSION: While malpractice lawsuits negatively affect professional well-being, this effect resolves with time. The effect on medical errors may be more permanent; orthopaedic surgeons who have experienced a lawsuit reported greater rates of medical errors even after these legal issues have been settled. Among orthopaedic surgeons dealing with lawsuits, supportive interventions to protect professional well-being and mitigate the factors which lead to greater medical errors are needed. LEVEL OF EVIDENCE: Prognostic Level III.

Assessing readmission databases: how reliable is the information?

Databases are being used to shape health care policy. However, the reliability of coding information entered into the databases may be difficult to validate. In this study, we assess readmission data from an institutional database that identified 1515 readmissions (708 patients) after total hip or total knee arthroplasty during a 5-year interval. After exclusions, 223 readmissions (190 patients) underwent medical record review. Bleeding, wound-related, and arthroplasty-related complications constituted most (62.8%) of readmissions. Bleeding and wound complications were nearly 6 times more frequently associated with readmission than venous thromboembolism events. On secondary review, there was discordance between the diagnosis obtained by a surgeon reviewer and coding for diagnoses consistent with periprosthetic infection (996.66, 77, 78, and 998.59) in 70% of cases. The findings of our study raise questions regarding the validity of accepting information obtained from larger databases without closer scrutiny.

Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses.

Background: This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods: This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results: Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (ß 7.1; P < .001) and with medication (ß 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (ß 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion: One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.

The burden and utility of routine follow-up at one year after primary arthroplasty.

AIMS: Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers. METHODS: All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit. RESULTS: Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed. CONCLUSION: Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85-89.

Caveat arthroplasty.

Caveat arthroplasty is arthroplasty undertaken to treat a presumed nonneoplastic disorder, which is later determined to be secondary to an extraarticular tumor. We identified 6 patients who had caveat arthroplasty before referral to our orthopedic oncology center. Three patients had completed arthroplasties at an average of 29 weeks before discovery of a neoplasm. Three arthroplasties were aborted after a neoplasm was discovered intraoperatively. Prearthroplasty radiographs of 4 patients were reviewed, all demonstrating evidence of malignancy. Caveat arthroplasty may be avoided if malignancy is considered preoperatively, particularly in patients with atypical symptoms, histories of cancer, and rapid periarticular bone loss. If a neoplasm is discovered intraoperatively, the arthroplasty should be aborted. Patients in whom malignancy is suspected should be referred to a musculoskeletal oncologist.

The Distribution of Underrepresented Minorities in U.S. Orthopaedic Surgery Residency Programs.

BACKGROUND: Orthopaedic surgery has generally lagged behind other surgical subspecialties with respect to racial and ethnic diversity in its U.S. residency programs. Efforts have been made to increase the number of underrepresented minorities (URMs) applying to orthopaedic surgery residencies; however, the impact on diversity at the residency program level is unknown. The purpose of this study was to determine whether orthopaedic surgery residency programs have become more racially diverse over time. METHODS: The Graduate Medical Education Track database was queried for individual racial/ethnic identification of orthopaedic surgery residents in U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited programs for 15 consecutive years (2002-2003 through 2016-2017). The number of URMs in each residency program during each academic year was recorded. The number of programs per year with no URMs, 1 URM, 2 URMs, and >2 URMs was recorded, and the change over time was assessed. RESULTS: The number of programs per year with >1 URM resident decreased over time, from 61 programs in 2002 to 53 programs in 2016, with the trough being 31 programs in 2010 (p < 0.0001). The number of programs per year without any URM residents increased over the period of study, from 40 programs in 2002 to 60 programs in 2016, with the peak being 76 programs in 2011 (p < 0.0001). CONCLUSIONS: The number of residency programs with >1 URM resident has decreased significantly over time, suggesting that diversity at the program level is limited. Program-level diversity should be further examined as a potential barrier to the recruitment of URMs to orthopaedics. Difficulty attracting URM residents to certain programs may have the unintended consequence of effectively limiting potential positions for these candidates, which can decrease the odds of minority students matching into orthopaedics and, therefore, perpetuate the cycle of lack of diversity in our field.

Benign synovial disorders.

Collectively, benign synovial disorders are not uncommon, and they may be seen in general orthopaedic practices. Symptoms are nonspecific, often delaying diagnosis. In fact, synovial chondromatosis, pigmented villonodular synovitis, synovial hemangioma, and lipoma arborescens often mimic each other as well as other, more common joint disorders in presentation, making diagnosis extremely difficult. It is important to diagnose these disorders correctly in order to provide appropriate treatment and avoid secondary sequelae, such as bone erosion and cartilage degeneration.

Patient Perceptions of Home Health Care Services After Total Joint Replacement.

Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].

Perspectives of Orthopedic Surgeons on Racial/Ethnic Disparities in Care.

OBJECTIVES: Racial/ethnic disparities in healthcare, including orthopedics, have been extensively documented. However, the level of knowledge among orthopedic surgeons regarding racial/ethnic disparities is unknown. The purpose of this study is to determine the views of orthopedic surgeons on (1) the extent of racial/ethnic disparities in orthopedic care, (2) patient and system factors that may contribute, and (3) the potential role of orthopedic surgeons in the reduction of disparities. METHODS: Three hundred five members of the American Orthopaedic Association completed a survey to assess their knowledge of racial/ethnic disparities and their perceptions about the underlying causes. RESULTS: Twelve percent of respondents believe that patients often receive different care based on race/ethnicity in healthcare in general, while 9 % believe that differences exist in orthopedic care in general, 3 % believe that differences exist within their hospitals/clinics, and 1 % reported differences in their own practices. Despite this, 68 % acknowledge that there is evidence of disparities in orthopedic care. Fifty-one percent believe that a lack of insurance significantly contributes to disparities. Thirty-five percent believe that diversification of the orthopedic workforce would be a "very effective" strategy in addressing disparities, while 25 % percent believe that research would be "very effective" and 24 % believe that surgeon education would be "very effective." CONCLUSION: Awareness regarding racial/ethnic disparities in musculoskeletal care is low among orthopedic surgeons. Additionally, respondents were more likely to acknowledge disparities within the practices of others than their own. Increased diversity, research, and education may help improve knowledge of this problem.