Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Movement is Life

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Movement is Life · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Did you know that African -Americans are more
0:02
than three times as likely as their white counterparts
0:04
to develop end -stage kidney disease? Now, just
0:07
think about that for a moment. How might a, well,
0:10
a deeply ingrained health disparity like that,
0:13
something seemingly unrelated to joints, how
0:15
might that unexpectedly impact a patient's ability
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to access life -changing surgery like, say, a
0:21
knee or hip replacement? Welcome back to The
0:24
Deep Dive. This is the show where we take a stack
0:26
of complex source material articles, research
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papers, maybe even your own notes, and we really
0:31
plunge into it. We try to extract the most important
0:34
nuggets of knowledge, the key insights. Our aim
0:37
is to give you that vital shortcut to being genuinely
0:39
well -informed, often with surprising facts,
0:42
hopefully, and enough context to help you see
0:44
the bigger picture. Today, we're embarking on
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a deep dive into something absolutely critical
0:49
in orthopedic surgery, but honestly, with implications
0:51
far beyond. Reoperative Optimization for Total
0:54
Joint Orthoplasty or TJA. We're talking hip and
0:56
knee replacements, but crucially we're approaching
0:59
this through a really specific and vital lens,
1:01
focusing squarely on health disparities. We'll
1:04
explore how existing health conditions, behavioral
1:06
factors, even social determinants that, well,
1:09
might seem disconnected from the operating theater
1:11
floor, how they can significantly impact whether
1:14
someone gets the surgery they need to restore
1:16
their mobility, their quality of life, and, importantly,
1:20
how well they recover afterwards. Our sources
1:22
for this deep dive are a series of powerful articles
1:24
from the Movement is Life series. They're published
1:27
in the JOS Journal. That's the Journal of the
1:30
American Academy of Orthopedic Surgeons. It's
1:32
a fantastic collection, really looking specifically
1:35
at optimizing patient access to TJA by addressing
1:38
these very disparities. And I'm joined today
1:40
by an expert who brings a wealth of knowledge
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and experience in synthesizing these complex
1:45
health issues, understanding the broader societal
1:47
implications. Thank you for guiding us through
1:50
this material. It's a real pleasure to be here.
1:52
These articles, they really do underscore a vital
1:55
conversation that's happening right now in orthopedics.
1:57
And it's one that echoes across healthcare disciplines,
2:00
actually. They make a compelling case, I think,
2:02
for viewing clinical readiness, not just through
2:05
a narrow medical lens, but within the full context
2:07
of a patient's life. That includes the systemic
2:10
factors that really shape their health journey.
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I agree completely. This isn't just about the
2:15
joint anymore, is it? It's about the whole person,
2:17
the world they live in. So let's jump straight
2:18
into it, a rapid -fire setup just to frame our
2:21
discussion. First question, what exactly is total
2:25
joint arthroplasty? And from the perspective
2:27
of these sources, why is a patient's preoperative
2:30
health status so particularly critical for its
2:33
success? All right, so total joint arthroplasty,
2:36
TJA, it's the surgical procedure to replace a
2:38
damaged hip or knee joint, usually due to severe
2:40
osteoarthritis, but other conditions too. It's
2:42
widely recognized as a highly effective intervention,
2:45
relieves pain, restores function. It can dramatically
2:48
improve a patient's quality of life. Now, the
2:50
sources we're looking at today make it exceptionally
2:52
clear that preoperative optimization is preparing
2:55
the patient to be in the best possible health
2:57
before they have this significant surgery. It's
2:59
not merely a suggestion. It's considered a cornerstone
3:02
of best practice. The primary aim, well, is to
3:05
minimize the risk of potential complications
3:07
and maximize the likelihood of a successful outcome.
3:11
And the list of potential complications they
3:13
detail is quite sobering, actually. Major cardiovascular
3:16
events like myocardial infarction, stroke, serious
3:19
infections, including the dreaded periprosthetic
3:21
joint infection, PGI. Then there are venous thromboembolism,
3:25
blood clots. unplanned hospital readmissions,
3:28
and tragically, even mortality. So the healthier
3:30
and more stable a patient's medical profile is
3:33
going into surgery, the more robustly they can
3:35
navigate the procedure and the recovery. It significantly
3:38
lowers their risk of these serious issues. OK,
3:41
right. So pre -op health isn't just a nice to
3:43
have. It's absolutely foundational for safety
3:46
and success. Now these sources, they repeatedly
3:49
highlight that certain health conditions, risk
3:52
factors, many needing this optimization, are
3:55
disproportionately prevalent in what they call
3:57
underserved communities or specific demographic
4:00
groups. Can you give us a sense of the scale
4:02
of these disparities as reported within these
4:04
articles? The scale is, well, it's Truly eye
4:07
-opening. And it really underscores the urgent
4:09
need these articles are trying to address. Across
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different health domains, we see significant
4:15
differences. For instance, the cardiovascular
4:17
article points out that while nearly half of
4:19
U .S. adults have hypertension, it's highest
4:21
among African Americans. When we look at chronic
4:24
kidney disease, CKD, that affects about 15 %
4:27
of the general adult population. But it's notably
4:30
higher in African Americans, around 16%, and
4:33
Hispanics, 14%. And as you mentioned right at
4:35
the start, African Americans face over three
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times the likelihood of progressing to end -stage
4:39
kidney disease compared to whites. Three times!
4:42
That's huge! It is. Smoking rates, too, are highest
4:46
in American Indian Alaskan Native populations.
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And they're clearly linked to lower income and
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education levels. Alcohol use disorder also shows
4:54
disproportionate rates in American Indians Alaskan
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Natives. Poor oral health, something we might
5:00
easily overlook in a surgical context, is documented
5:02
as being much more common in African Americans
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and Hispanics. Infectious diseases like HIV and
5:07
hepatitis C, often carrying significant social
5:10
stigma, they also disproportionately affect African
5:13
Americans and Hispanics. Mental illness, while
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widespread, is shown to be linked to the burden
5:17
of discrimination experienced by racial and ethnic
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minorities. African Americans specifically highlight
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it as being more prone to chronic depression,
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facing significant hurdles in accessing treatment.
5:27
And finally, housing insecurity. Affecting 10
5:31
-15 % of Americans, it disproportionately impacts
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low -income individuals and racial minorities.
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These aren't minor statistical fluctuations,
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you know. They represent substantial persistent
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burdens, unevenly distributed across populations,
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often due to systemic factors, historical inequities.
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That really drives home the point, doesn't it?
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We're not starting from an equal playing field
5:50
when patients present for TJA. It's a landscape
5:53
of, well, overlapping vulnerabilities. So finally
5:57
for this setup, the title of this series, Movement
5:59
is Life Optimizing Patient Access. What's the
6:03
core challenge or maybe the overarching mission
6:06
that these articles collectively seek to address
6:09
regarding these specific disparities and equitable
6:12
access to joint replacement surgery? The core
6:14
mission, as it's articulated throughout the series,
6:17
it's fundamentally about promoting health equity.
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working towards eliminating musculoskeletal disparities.
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TJA is a profound surgery. It literally gives
6:26
people back their ability to move, which is so
6:29
fundamental to life, isn't it? Independence,
6:31
well -being. The central challenge these articles
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confront is that many of the health conditions
6:35
and risk factors that necessitate preoperative
6:38
optimization, things like poorly controlled blood
6:40
pressure, kidney disease, smoking, even unstable
6:43
housing, these are precisely the ones that are
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more prevalent in underserved groups. Right,
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the very groups who need the surgery often face
6:49
the biggest hurdles getting ready for it. Exactly.
6:52
And this is often due to systemic issues, including
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the cumulative impact of discrimination, limited
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access to consistent primary care over a lifetime,
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lack of resources. The articles powerfully argue
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that preoperative optimization can indeed serve
7:06
as a crucial pathway to improving access to TJA,
7:09
helping to reduce these disparities. But... And
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this is a critical caveat they make only if these
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optimization programs are intentionally designed
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with the unique needs and challenges of these
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underserved communities firmly in mind. They
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spend considerable time cautioning against the
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pitfalls of strict, inflexible preoperative cutoffs.
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Things like rigid BMI limits, absolute requirements
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for dental clearance, or mandatory unsupported
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smoking cessation without considering the patient's
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ability to access the necessary support. So just
7:38
saying you must stop smoking isn't enough if
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the support isn't there. Precisely. Their argument
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is that the evidence suggests these kinds of
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inflexible criteria can actually exacerbate existing
7:48
disparities. They disproportionately exclude
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patients from minority or indigent populations.
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It potentially leads to what the authors call
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carry -picking, selecting healthier, lower -risk
8:00
patients, which ultimately widens rather than
8:03
narrows. health equity gaps. OK, let's unpack
8:05
this further then. It sounds like the conversation
8:07
isn't just about, you know, ticking off a medical
8:10
checklist before surgery. It's about understanding
8:12
and navigating a deeply complex landscape of
8:15
health, social factors, systemic barriers that
8:18
patients face long before they even meet an orthopedic
8:21
surgeon. Exactly. It forces us as health care
8:23
providers, as systems, to look beyond the purely
8:25
clinical data points on a patient's chart. We
8:28
need to consider the broader determinants of
8:30
health. the conditions in which people are born,
8:32
grow, live, work, age, and how these profoundly
8:35
impact a patient's ability to reach a point where
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elective surgery like PJA is actually safe and
8:40
successful for them. Right. So building on that,
8:44
let's really dive into some of these specific
8:46
factors the sources examine in detail. We'll
8:48
start with what we might think of as the more
8:50
traditional medical comorbidities, but always
8:53
keeping that lens of disparities and systemic
8:55
challenges in focus. An excellent place to begin.
8:58
The sources dedicate specific articles to exploring
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a range of health factors, how they interact
9:03
with TJA outcomes and access, and they consistently
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highlight where disparities exist. One condition
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that's paramount for any surgical candidate and
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which the sources delve into with some striking
9:14
statistics is cardiovascular health. Indeed.
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The article specifically on cardiovascular health
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before TJA, it paints a very clear picture of
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the burden. It notes that a significant portion
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of American adults struggle with these issues.
9:28
About 6 .7 % diagnosed with coronary artery disease
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and a massive 45 % having hypertension, high
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blood pressure. Perhaps the most alarming figure
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cited is that fewer than 25 % of adults with
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these conditions have them properly managed and
9:41
controlled. Fewer than 25%. Think about that.
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less than a quarter receiving adequate control
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for conditions that significantly increase surgical
9:49
risk. That's an enormous pool of patients, isn't
9:51
it, who might be seeking TJA while carrying uncontrolled
9:55
cardiovascular risks. Precisely. And as we touched
9:58
on in the rapid fire, the disparity is starkly
10:00
visible here. Hypertension is most prevalent
10:03
among African Americans, and this is explicitly
10:06
linked in the source to lower socioeconomic status
10:08
and education level. So right away, a major clinical
10:12
risk factor is shown to be deeply intertwined
10:14
with social determinants of health. How does
10:16
having uncontrolled cardiovascular issues directly
10:19
impact someone undergoing or planning for a joint
10:22
replacement? The impact, according to these sources,
10:24
is substantial. Wide -ranging. Heart disease
10:27
is strongly associated with a whole host of negative
10:30
post -operative complications. These include
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cardiovascular and cerebrovascular events, heart
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attacks, strokes, pulmonary complications affecting
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the lungs, issues with blood clotting, coagulopathy,
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increased rates of hospital readmission, and
10:44
very significantly higher mortality rates. The
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article underscores the gravity by stating that
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ischemic heart disease is, in fact, the most
10:51
common cause of death following total joint arthroplasty.
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Furthermore, patients from lower socioeconomic
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backgrounds are specifically identified as being
11:00
at a higher risk for myocardial infarction heart
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attack after TJA. even independent of other factors.
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The most common cause of death. That statistic
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alone powerfully underlines why optimizing cardiovascular
11:11
health isn't just beneficial, it's potentially
11:13
life -saving. And the sources introduce this
11:15
concept of allostatic load in this context. Can
11:18
you explain that a bit? Yes, this is a really
11:21
important concept they bring forward. Allostatic
11:23
load, it's described as the cumulative wearing
11:26
away of the body that results from chronic exposure
11:29
to stress. The article explicitly links the burden
11:33
of discrimination which is disproportionately
11:35
placed upon African American and Hispanic populations
11:38
to an increase in their risk of developing heart
11:40
disease. This framework helps explain how systemic
11:43
social issues, the stress of experiencing discrimination
11:46
over a lifetime, can manifest directly as increased
11:50
biological risk factors. It further compounds
11:52
the preoperative challenges faced by these groups.
11:55
That's a profound connection. It highlights that
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we're not just dealing with individual patient
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factors, are we, but the cumulative impact of
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societal stress, inequity affecting biological
12:04
health. So given these risks and disparities,
12:07
what optimization strategies do the sources recommend
12:09
for improving cardiovascular health before TJA?
12:12
Well, they advocate for a thorough and proactive
12:14
preoperative assessment process. This includes
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evaluating factors you might not immediately
12:19
connect to heart health, like food security,
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recognizing that access to nutritious food directly
12:25
impacts dietary choices and health. An interesting
12:28
link. Core strategies involve encouraging lifestyle
12:31
modifications, improving diet, increasing physical
12:34
activity, alongside appropriate pharmacologic
12:37
treatments to manage conditions like hypertension,
12:40
hyperlipidemia. A consistent theme across these
12:43
articles, and one highlighted specifically here,
12:45
is the invaluable role of nurse navigators. They
12:48
are seen as critical guides for patients, helping
12:51
them access resources, adhere to recommendations.
12:54
Nurse navigators sound like a crucial piece of
12:56
the puzzle, really, for making optimization programs
12:58
actually work, especially for complex patients.
13:01
What about more specific clinical guidance, managing
13:04
conditions like hypertension immediately before
13:06
surgery? The sources provide some clinical specifics,
13:09
yes. They recommend continuing beta -blocker
13:12
medications preoperatively, citing evidence this
13:14
class of drugs can decrease both 30 -day and
13:17
one -year mortality rates after surgery. While
13:20
they caution against using strict universal blood
13:22
pressure cutoffs that could exclude patients
13:24
unnecessarily, they do note that a blood pressure
13:27
reading above, say, 180110 may be a trigger point.
13:31
It might warrant delaying elective TJA to allow
13:34
time for better control. Okay. For patients with
13:37
more complex cardiovascular histories or multiple
13:39
comorbidities, co -management with internal medicine
13:42
or cardiology specialists is recommended, potentially
13:45
extending into the post -operative period. Red
13:48
flag's warranting a pre -op cardiology referral
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explicitly mentioned include poorly controlled
13:52
hypertension, a history of prior coronary interventions
13:55
like stents or bypass surgery, recent heart attack,
13:58
or the need for complex management of antiplatelet
14:01
or anticoagulation meds. That sounds like a layered
14:03
approach, requires significant coordination across
14:06
disciplines, patient support. This brings up
14:09
a potentially challenging trend, the shift towards
14:11
outpatient total joint arthroplasty. How might
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this trend potentially disadvantage patient populations
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who carry these higher comorbidity burdens, particularly
14:21
those from underserved groups? This is a really
14:24
important question the source raises, and it's
14:26
presented as a potential concern, yes. they express
14:29
worry that the increasing move towards performing
14:32
TJA in outpatient or ambulatory surgical settings
14:35
could inadvertently disadvantage patient populations
14:38
who have higher rates of complex medical conditions.
14:41
This is particularly true if these outpatient
14:43
centers aren't adequately equipped with the necessary
14:46
support infrastructure. Things like dedicated
14:48
nurse navigators or physician extenders who can
14:50
help manage these comorbidities in the perioperative
14:53
period. Right, the support needs to follow the
14:55
patient setting. Exactly. The article notes that
14:58
African American patients currently receive a
15:00
disproportionately higher percentage of their
15:02
TJA procedures in inpatient settings compared
15:05
to whites, which they suggest could reflect this
15:08
underlying higher co -morbidity burden within
15:11
that group. They also point out that African
15:13
Americans have lower overall TJA utilization
15:16
rates to begin with. The concern is that without
15:19
robust support systems in outpatient settings,
15:22
this procedural shift could potentially exacerbate
15:24
existing disparities in outcomes and access for
15:27
these vulnerable populations. That really highlights
15:29
the need for careful planning, investment, and
15:32
support infrastructure as surgical settings evolve.
15:35
Okay, shifting gears slightly, the series also
15:37
takes an in -depth look at chronic kidney disease,
15:39
CKD. What does the source material reveal about
15:42
CKD in the context of TJA? Chronic kidney disease
15:45
is another significant and prevalent comorbidity
15:48
with a clear link to TJA. The articles state
15:51
that approximately 15 % of U .S. adults have
15:54
CKD. And again, we see that pattern of disparities.
15:58
Prevalence is higher in underserved communities,
16:00
affecting 16 % of African Americans and 14 %
16:03
of Hispanics. The disparity becomes even more
16:06
pronounced when looking at end -stage kidney
16:08
disease, ESKD, the most severe form, where, as
16:11
we said, African Americans are over three times
16:13
more likely to develop it compared to whites.
16:15
ESKD often requires dialysis or kidney transplantation.
16:19
So it's not just about having CKD, but the severity
16:21
and the distribution of that severity across
16:23
populations. Exactly. And the sources highlight
16:25
how CKD rates are also higher in geriatric populations
16:29
and those who are socioeconomically disadvantaged.
16:32
What's particularly striking is how these risk
16:34
factors tend to cluster. The article points out
16:36
these are often the very same groups who have
16:38
high rates of hip and knee osteoarthritis, the
16:41
condition prompting the TJA. and who also have
16:44
elevated rates of other related comorbidities
16:46
like obesity, diabetes, heart disease, hypertension.
16:49
It paints a picture of intertwined health challenges
16:52
where multiple risks accumulate in the same individuals
16:54
and communities. If we connect this clustering
16:57
of risks to the bigger picture of surgery, how
16:59
does CKD specifically impact the safety and success
17:02
of a total joint arthroplasty? The surgical impact,
17:06
as detailed in the sources, is considerable.
17:08
They state unequivocally that chronic kidney
17:10
disease, even at early stages, is associated
17:13
with increased risks of post -operative readmission,
17:16
higher overall complications, and increased mortality
17:19
after TJA. For patients on hemodialysis, meaning
17:22
they have end -stage kidney disease, the risks
17:25
are even higher, including a significantly increased
17:28
risk for periprosthetic joint infection, PGI,
17:31
which is, as we know, a devastating complication.
17:34
While receiving a kidney transplant can significantly
17:37
lower these surgical risks, the sources note
17:39
that there remains varying clinical opinion on
17:41
whether patients on dialysis are truly safe candidates
17:44
for elective TJA. Some clinicians recommend delaying
17:48
surgery until after a successful kidney transplant,
17:50
if that's an option for the patient. But you
17:52
mentioned earlier that access to kidney transplant
17:54
is itself marked by disparities. That complicates
17:56
things further, doesn't it? This is where the
17:58
issues become particularly complex intersecting.
18:00
The sources explicitly state that individuals
18:03
from low socioeconomic backgrounds and underrepresented
18:06
minority groups experience unequal access to
18:09
kidney transplantation compared to other populations.
18:12
What this means in the context of TJA is that
18:15
a larger percentage of patients who are candidates
18:17
for joint replacement and are on dialysis are
18:20
likely to come from these very groups who face
18:22
additional systemic barriers to accessing a lifesaving
18:26
transplant first. The authors offer a practical
18:29
recommendation here. They suggest that orthopedic
18:31
surgeons should proactively communicate the severity
18:34
of a patient's osteoarthritis, the impact it
18:36
has on their quality of life, mobility with their
18:39
nephrology, and transplant teams. They propose
18:42
that highlighting the patient's need for TJA
18:44
could potentially influence their priority or
18:47
position on a kidney transplant wait list, thereby
18:50
addressing two major health needs concurrently,
18:52
advocating for the patient within the broader
18:54
healthcare system. That's a crucial point about
18:56
communication and advocacy across specialties,
18:59
really important. What about optimizing patients
19:02
who do have CKD before their TJA? Preoperative
19:05
screening for existing or undiagnosed kidney
19:07
disease is highlighted as a critical first step.
19:10
This involves a comprehensive evaluation that
19:12
goes beyond just serum cratinine. It includes
19:15
assessing glomerular filtration rate, GFR, a
19:18
key measure of kidney function checking electrolyte
19:20
levels, hemoglobin levels to assess for anemia,
19:23
which is common in CKD, evaluating volume status,
19:27
and ensuring blood pressure is as controlled
19:28
as possible. Working closely with the patient's
19:31
primary care physician is deemed vital, and referral
19:34
to a nephrology specialist is recommended for
19:36
patients with stage 3 or greater CKD. Optimization
19:40
strategies specific to CKD patients preparing
19:42
for TJA include carefully managing their fluid
19:45
volume status, providing iron supplementation
19:48
if they have anemia, and addressing any issues
19:50
with blood clotting disorders, potentially with
19:52
consultation from hematology. The sources also
19:55
include a specific clinical detail. They recommend
19:58
avoiding blood transfusions if at all possible
20:00
for patients who are eligible for kidney transplant.
20:03
Receiving trans -used blood can lead to the development
20:05
of antibodies that might make future transplant
20:07
more difficult or increase the risk of rejection.
20:09
So another condition requiring that multidisciplinary
20:12
coordination, attention to very specific clinical
20:15
details, all while recognizing the underlying
20:18
disparities that might make managing it more
20:20
challenging for certain patients. Let's look
20:23
at anemia next. Anemia, or low red blood cell
20:26
count, is surprisingly common. It affects around
20:29
6 % of U .S. adults overall. But again, the sources
20:32
point out it's more prevalent in specific patient
20:34
groups, including the elderly, those with existing
20:37
conditions like CKD, cancer, heart failure, diabetes.
20:40
This again illustrates that pattern of intersecting
20:42
risks and vulnerability we've noted. And the
20:45
surgical risk of anemia in TJA. What do the sources
20:48
say? They're very direct on this point. Preoperative
20:51
anemia is identified as a strong and independent
20:53
predictor of needing a postoperative blood transfusion.
20:56
Beyond the risks associated with transfusion
20:58
itself, preoperative anemia is also linked to
21:01
increased overall morbidity and mortality after
21:03
surgery. They specifically mention iron deficiency
21:06
anemia as a common type that's important to identify
21:09
because it is highly treatable before surgery
21:11
through iron supplementation. This topic also
21:14
leads into a discussion of sickle cell disease,
21:16
doesn't it? A related but distinct issue. Yes.
21:20
The same article broadens its scope to include
21:22
sickle cell disease, SCD. This is a significant
21:26
inherited blood disorder predominantly affecting
21:28
black individuals, occurring in about 1 in 365
21:32
black births, 1 in 16 ,300 Hispanic births in
21:35
the U .S., affecting an estimated 100 ,000 Americans
21:38
overall. A major orthopedic manifestation of
21:41
SCD is osteonecrosis bone death due to lack of
21:45
blood supply, particularly affecting the femoral
21:46
head, the ball of the hip joint. Between 10 %
21:49
and 40 % of patients with SCD will develop osteunacrosis
21:53
severe enough to require total hip arthroplasty.
21:56
This means a TJA in the context of SCD often
21:58
involves younger, more active patients compared
22:01
to the typical older patient with osteoarthritis.
22:03
which presents unique surgical considerations.
22:05
Right. And here's where it gets really interesting
22:07
or perhaps challenging from a surgical perspective.
22:10
The sources detail specific surgical challenges
22:12
and risks that are unique to patients with sickle
22:14
cell disease undergoing TJA. What are those?
22:16
They detail significant technical challenges
22:18
and risks stemming directly from the disease
22:20
itself. SCD causes changes in the bone marrow
22:23
fatty infiltration, sclerosis or hardening of
22:26
the bone, narrowing of the femoral canal which
22:28
is important for implant placement, bony defects.
22:31
These bone changes can increase the risk of complications.
22:34
Things like implant malposition, prosthetic dislocation
22:37
after surgery, aseptic cup loosening where the
22:39
implant comes loose without infection, delayed
22:41
wound healing, Also, the need for revision surgery,
22:45
osteomyelitis or bone infection, systemic sepsis,
22:48
longer hospital stays compared to average TJA
22:51
patients, and higher rates of readmission. And
22:53
in the articles also point out that patients
22:55
with SCD often face barriers accessing appropriate
22:58
care in general, adding another layer of difficulty.
23:00
They do. This adds another layer of complexity
23:03
to their surgical journey. So the optimization
23:05
strategies recommended for SCV patients undergoing
23:08
TJA are quite specific, comprehensive. A key
23:12
intervention is preoperative red blood cell transfusions.
23:16
The goal is to dilute the concentration of sickle
23:18
cells in the patient's blood with healthy red
23:20
cells, aiming for a hemoglobin level above 10
23:23
GDL before surgery. This helps improve oxygen
23:26
delivery, reduces the risk of sickle cell related
23:29
complications. Crucially, the sources highlight
23:32
the need for careful proactive pain monitoring
23:35
during the perioperative period. and they explicitly
23:38
point out the sad reality of potential bias from
23:40
health care providers regarding pain management
23:42
in this patient population, which can lead to
23:45
undertreatment. That's a really serious point
23:46
about bias. It is. They recommend aggressive
23:49
strategies for preventing deep vein thrombosis,
23:51
DVT, and careful management of perioperative
23:54
fluids and blood loss. Preoperative consultations
23:57
are absolutely vital, requiring a multidisciplinary
24:00
team, including hematology, anesthesia, infectious
24:03
disease specialists, cardiology. For pain control,
24:07
they specifically recommend using scheduled NSAIDs
24:10
in combination with analgesics to ensure adequate
24:13
pain relief, counteract potential bias, and as
24:16
-needed dosing. They also suggest documenting
24:18
a clear, well -outlined analgesic plan before
24:21
surgery to avoid confusion or conflict among
24:24
the care team during the perioperative period.
24:26
That just underscores the critical need for a
24:29
coordinated, informed approach, doesn't it? Particularly
24:32
for patients facing both complex medical conditions
24:34
and potential healthcare biases? Okay, we've
24:37
covered some significant medical conditions.
24:39
But these sources also highlight how lifestyle
24:41
factors, social determinants, infectious diseases,
24:43
often carrying stigma, create additional hurdles
24:46
and disparities for TJA candidates. Indeed. The
24:49
sources transition here to examining several
24:51
factors that, while often behavioral or linked
24:54
closely to social determinants, have a profound,
24:58
often underestimated impact on a patient's readiness
25:00
for surgery, their outcomes, and equitable access
25:03
to care. Smoking is a classic, modifiable risk
25:06
factor discussed before surgery. But the source
25:09
material reveals significant disparities here,
25:12
too, surprisingly. Absolutely. While the overall
25:14
rate of smoking among U .S. adults is around
25:16
13 .7%, the disparities highlighted in the source
25:19
are quite stark. Smoking rates are highest among
25:22
American, Indian, Alaskan, Native individuals.
25:25
And they're clearly linked to specific socioeconomic
25:27
factors, particularly having a GED rather than
25:29
higher education, living in lower -income households,
25:32
residing in rural areas, areas, having a disability,
25:35
being part of the LGBTQ plus community, experiencing
25:38
psychological distress. The article also raises
25:41
concern about the recent rise in vaping, suggesting
25:43
it may become a pathway to future smoking and
25:46
associated health issues. And they explicitly
25:48
link these disparities to predatory marketing
25:50
practices. That's quite a statement. Yes. This
25:53
is a critical point they make. The article states
25:55
that disproportionate and predatory marketing
25:57
strategies by the tobacco industry specifically
26:00
target vulnerable populations. They mention working
26:03
-class individuals, residents of predominantly
26:05
blackened or low -income geographic areas, the
26:08
LGBTQ plus community. The sources explicitly
26:11
identify this targeted marketing as a causative
26:14
factor contributing to these higher rates of
26:16
smoking and the increased difficulty in quitting
26:18
among these communities. That really adds a systemic
26:20
layer, doesn't it, to what is often framed purely
26:23
as an individual's health choice? What is the
26:25
specific negative impact of smoking on TJA outcomes
26:28
reported in the sources? The impact is significant.
26:31
affects multiple aspects of the surgical process
26:33
and recovery. Smoking impairs wound healing,
26:37
which can lead to serious infections, both superficial
26:39
and deep. It delays bone healing, increasing
26:43
the risk of complications related to how the
26:45
implant integrates with the bone, potentially
26:47
leading to aseptic loosening later on. Furthermore,
26:51
it significantly increases the risk of major
26:53
medical complications such as myocardial infarction,
26:56
cardiac arrest, pneumonia, sepsis in the perioperative
26:59
period. Smokers are also more likely to require
27:02
prolonged opioid use for pain control and face
27:05
higher rates of hospital readmission and mortality.
27:07
That's quite an array of risks. Given that smoking
27:10
is a modifiable risk factor, does quitting immediately
27:12
before surgery make a difference, even short
27:15
-term? The sources confirm that quitting before
27:17
surgery is crucial. It does lower the risk of
27:21
complications compared to continuing to smoke.
27:23
They state that even temporary cessation for
27:26
a shorter period as four to eight weeks leading
27:28
up to surgery has been shown in studies to be
27:30
beneficial in reducing perioperative complications.
27:33
What role does the orthopedic surgeon play in
27:35
this process? The sources highlight the surgeon's
27:38
position as providing a teachable moment. Patients
27:41
facing a major surgery are often more motivated
27:44
to make health changes. The surgeon can leverage
27:46
this by strongly counseling them on the importance
27:49
of quitting. However, they also acknowledge the
27:51
significant challenge. Smoking is highly addictive.
27:55
They compare its addictive potential to that
27:57
of cocaine and heroin. They're realistic about
28:00
the difficulty many patients face in successfully
28:03
quitting. What did the survey of orthopedic institutions,
28:06
which is mentioned across these articles, reveal
28:08
about how smoking cessation is actually handled
28:10
in practice before TJA? Is it consistent? The
28:14
survey results reported in the article revealed
28:16
widespread variability and a general lack of
28:19
structured formal preoperative smoking cessation
28:22
protocols across the seven major orthopedic institutions
28:25
they surveyed. Only two institutions reported
28:27
that their surgeons routinely told patients they
28:29
should be smoke -free before surgery. And only
28:32
one of those sometimes verified this with cotinane
28:35
levels, a marker of nicotine exposure. Only one?
28:38
Wow. Crucially, the survey found no evidence
28:41
of systematic hard stops, meaning automatic cancellation
28:44
or postponement of surgery based solely on a
28:46
patient's smoking status. This suggests a significant
28:49
gap. a clear opportunity for developing and implementing
28:52
more consistent, effective, preoperative smoking
28:55
cessation programs. When discussing effective
28:58
programs, the sources mentioned comprehensive
29:00
approaches are best. Incorporating medical management,
29:03
behavior modification techniques, motivational
29:06
interviewing, these are typically described as
29:08
prolonged intensive programs. They list pharmacologic
29:11
aids that can assist patients. Over -the -counter
29:14
nicotine replacement products, varenicline, bupropion.
29:17
They mentioned the past controversy and black
29:19
box warnings associated with some of these meds.
29:22
But note, these were removed in 2016 based on
29:24
newer evidence. Although label warnings about
29:26
potential effects on behavior and mood do remain.
29:29
They also touch on the complexities of actually
29:31
verifying abstinence through testing, don't they?
29:34
Yes. The article discusses the challenges of
29:36
relying solely on biochemical verification, like
29:39
cottonine testing. Cottonine levels can vary
29:41
based on factors like race, ethnicity, sex. Understanding
29:46
the half -lives of nicotine and cotinine is complex.
29:49
They argue that while testing can be a tool,
29:52
it should ideally be used as a conversation starter,
29:55
a way to understand the patient's quitting journey,
29:57
their support needs, rather than simply a strict
30:00
cut -off criterion that could penalize vulnerable
30:02
patients who struggle despite trying. This leads
30:05
them to reiterate an important point. Surgeons
30:07
must weigh the risks associated with smoking
30:09
for a specific patient against the profound benefits
30:12
that TJA can offer. respecting the patient's
30:15
autonomy, the ethical principle of not causing
30:17
harm, creating strict and flexible cutoffs for
30:20
modifiable risks like smoking without providing
30:23
adequate support for patients to address these
30:25
factors, risks increasing healthcare disparities,
30:28
similar to the concerns raised about strict BMI
30:29
cutoffs which have been shown to disproportionately
30:32
affect disadvantaged populations. That ethical
30:35
consideration about balancing risk, benefit,
30:37
and access is a critical thread running through
30:39
these articles, isn't it? Let's move on to alcohol
30:42
and substance use disorders, AUD and SUD. The
30:45
sources present significant prevalence data here,
30:48
too. They do, and these are factors with substantial
30:50
implications for surgical safety and outcomes.
30:53
The sources report that approximately 25 .1 %
30:56
of U .S. adults engaged in binge drinking in
30:58
the past year, and 5 .8 % beat the criteria for
31:02
an alcohol use disorder diagnosis. Once again,
31:05
we see clear disparities. AUD and heavy drinking
31:07
rates are highest among American Indian Alaskan
31:10
Native individuals. Heavy episodic drinking is
31:12
highest among Latinx and American Indian populations.
31:15
AUD is also more prevalent among individuals
31:17
who are unemployed, have lower levels of education,
31:20
or are single and divorced. And how are alcohol
31:22
and broader substance use linked? Are they often
31:24
seen together? They are often closely intertwined,
31:27
yes. The sources cite data showing that a significant
31:30
majority, 74 percent, of individuals struggling
31:33
with substance use disorder also have an alcohol
31:37
use disorder. This highlights the critical importance
31:39
of screening patients for both alcohol and substance
31:42
use issues simultaneously when assessing surgical
31:45
candidates. What about the prevalence and impact
31:47
of other forms of substance use beyond alcohol?
31:50
Overall recreational drug use is reported to
31:53
affect 11 .7 % of individuals age 12 and older.
31:57
It's cited as a major contributor to preventable
31:59
morbidity and mortality in the U .S. Similar
32:02
to AUD, it disproportionately affects vulnerable
32:04
populations, with American Indians showing the
32:07
highest rates of recreational drug use. Substance
32:09
use is also tightly linked with mental illness.
32:12
The article points out a specific vulnerability
32:14
for women who may develop prescription opioid
32:16
dependence more rapidly than men, and often face
32:19
additional barriers to treatment, sometimes forgoing
32:22
it due to lack of support or childcare responsibilities.
32:25
You mentioned discrimination earlier as a factor
32:27
in cardiovascular health. Is that connection
32:30
present in the context of AUD, SUD as well? Does
32:32
it play a role here? Absolutely, and the sources
32:35
are very explicit about this. They state that
32:37
discrimination based on race, ethnicity, sex,
32:40
or sexual preference is deeply interwoven with
32:43
conditions like depression, anxiety, and substance
32:45
use. This discriminatory burden is linked to
32:48
reduced access to mental health and addiction
32:50
treatment services, and ultimately contributes
32:52
to worse mental health outcomes for affected
32:55
groups. So understanding that context, how does
32:57
preoperative, AUD, or SUD specifically impact
33:00
the process and outcomes of TJA surgery itself?
33:03
The surgical implications are significant. They
33:05
span both the perioperative and postoperative
33:08
periods. Preoperative unhealthy alcohol use can
33:11
lead to difficulties for anesthesia providers
33:12
affecting dosing, effectiveness of anesthetics,
33:15
pain meds. It can cause issues maintaining stable
33:18
blood pressure during surgery. Increase the risk
33:21
of bleeding, developing venous thromboembolism,
33:24
blood clots. In the postoperative period, it's
33:27
associated with higher rates of infections, poor
33:29
wound healing or disruptions, cardiopulmonary
33:32
complications, increased length of hospital stay.
33:35
Alcohol also has complex interactions with various
33:37
medications used during recovery, and can significantly
33:41
disrupt a patient's ability to be compliant with
33:43
postoperative instructions, rehabilitation protocols,
33:46
and non -prescription drug use before surgery.
33:48
Some more risks. Preoperative non -prescription
33:51
drug use or abuse is linked to increased risks
33:54
of serious complications, like periprosthetic
33:56
joint infection, wound complications, aseptic
33:59
loosening of the implant. One of the most striking
34:02
findings highlighted in the sources is that preoperative
34:05
use of opioids, including both prescription and
34:08
non -prescription, is identified as the number
34:10
one predictor of prolonged chronic postoperative
34:13
opioid use. The number one predictor. Yes. Patients
34:16
using opioids before surgery have a four -fold
34:19
increased risk of needing a second opioid prescription
34:21
after discharge. and a staggering 12 -fold increased
34:25
risk of continued opioid use a year or more after
34:28
their total hip arthroplasty compared to opioid
34:31
-naive patients. Furthermore, substance use before
34:34
surgery is also associated with less perceived
34:36
benefit in terms of improvements in pain and
34:38
functional scores after TJA. That's a powerful
34:41
predictor with really long -term implications.
34:43
What strategies are recommended then for addressing
34:45
AUDSED in TJA candidates? The sources emphasize
34:48
the critical role of validated screening tools
34:51
in identifying patients at risk. Tools like the
34:54
Aud8C for alcohol use, the DAS20 for drug use.
34:57
They're recommended and can be administered efficiently
34:59
by any member of the surgical care team. For
35:01
patients with positive screens, further assessment
35:04
to determine the level of dependence is crucial,
35:06
potentially using tools like the CIWAR for alcohol
35:09
withdrawal risk. Patients identified as being
35:12
at high risk of experiencing medically significant
35:14
withdrawal symptoms need medically supervised
35:17
withdrawal protocols before surgery. Abstinence
35:19
is generally recommended, ideally for 3 to 8
35:21
weeks prior to surgery, although the duration
35:23
may need tailoring. Interventions mentioned include
35:26
education, counseling, referral to mutual help
35:28
groups like AA or NA, psychosocial interventions,
35:32
and, when appropriate, pharmacologic treatments.
35:34
Referring patients to the formal four -to -Kate
35:36
Wenk addiction treatment programs is suggested
35:38
for those with more severe dependence. A recurring
35:41
and vital theme here, consistent with other areas
35:43
of optimization for vulnerable populations, is
35:45
the crucial role of a supportive care team. nurse
35:48
navigators, primary care physicians, social workers,
35:51
addiction counselors, working collaboratively
35:53
with the patient. Right, that team approach again.
35:56
This multidisciplinary support is essential for
35:58
monitoring progress, providing encouragement
36:01
during the challenging process of achieving abstinence
36:03
or reducing use, and critically, ensuring patients
36:07
don't feel abandoned or penalized by the surgical
36:09
team due to their substance use issues. Shared
36:12
decision making involving the patient and the
36:14
plan is highlighted as important for fostering
36:17
buy -in and adherence. For patients with a history
36:20
of recent non -prescription drug use, toxicology
36:23
screens are recommended to inform management.
36:25
Communication with the patient's primary care
36:27
provider or existing addiction clinics is essential.
36:31
For positive marijuana tests, while not necessarily
36:33
a hard stop unless a significant anesthesia risk,
36:37
the sources suggest this should prompt a conversation.
36:40
About reducing or eliminating use, immediately
36:42
pre -opt to minimize potential respiratory effects
36:44
or interactions. It sounds like a far more involved
36:47
process than simply asking about substance use.
36:50
It really requires building trust and a robust
36:52
support system around the patient. Absolutely.
36:54
It's about treating the underlying disorder and
36:57
providing a pathway to surgical readiness rather
37:00
than just creating another barrier to care. Let's
37:03
look at oral health next. This might seem less
37:06
directly related to a knee or hip replacement,
37:09
perhaps, but the sources bring it up in the context
37:11
of surgical risk and disparities. It does indeed.
37:15
Poor oral health is a significant issue in the
37:17
U .S. generally. But the source has highlighted
37:19
significantly more common in African -Americans,
37:22
Hispanics, and other racial and ethnic minority
37:24
groups. They cite alarming statistics, like almost
37:28
one in five low -income adults reporting their
37:30
mouth and teeth being in poor condition. A major
37:33
systemic barrier contributing to these disparities
37:35
is access to dental care. Nearly a third, 29
37:38
% of Americans, lack dental insurance. How does
37:41
the state of a patient's oral health specifically
37:44
link to the risks of total joint arthroplasty?
37:46
What's the connection? The primary concern is
37:48
that active infections anywhere in the body,
37:50
including the mouth, are considered a potential
37:52
risk factor for periprosthetic joint infection,
37:55
PGI. As we've discussed, PGI is one of the most
37:59
feared, expensive complications of arthroplasty,
38:02
often requiring complex, prolonged treatments,
38:04
sometimes multiple surgeries. The forces list
38:07
several risk factors for significant dental problems
38:09
relevant to surgical planning. a patient reporting
38:11
pain or symptoms from their teeth gums, current
38:13
tobacco or narcotic use, a recent dental visit
38:16
due to symptoms, a history of root canal treatment.
38:19
Conversely, having regular dental care seems
38:21
protective. This raises a pertinent question,
38:23
doesn't it? Is formal dental clearance often
38:26
required before other types of surgery like heart
38:28
surgery truly necessary or beneficial before
38:31
TJA? What do the sources say? This is where the
38:34
sources reveal a surprising degree of ambiguity.
38:37
Lack of consensus in the existing literature
38:40
and clinical practice. They mentioned studies
38:42
that have questioned the necessity, or even the
38:44
benefit, of routine preoperative tooth extractions
38:48
specifically to prevent PGI. Intriguingly, one
38:52
study they cite found that patients who underwent
38:54
tooth extractions immediately before their arthroplasty
38:57
actually experienced a higher rate of overall
39:00
perioperative complications. Although this study
39:03
did not find an increased risk of PGI specifically
39:06
in those who had extractions. Higher complications.
39:08
That's counterintuitive. It is. This ambiguity
39:11
leads the authors of the Oral Health article
39:13
to question whether mandating preoperative dental
39:16
extraction for all patients with potential issues
39:18
is genuinely warranted or beneficial based on
39:21
current evidence. Supporting this lack of clear
39:23
guidance, the survey of the seven orthopedic
39:26
institutions found significant variability, a
39:28
general absence of a defined standard screening
39:31
process or a consistent definition of what constitutes
39:33
adequate dental clearance across these institutions.
39:36
It varied widely. No clear consensus in the evidence
39:40
or in practice regarding mandatory dental clearance
39:43
before TJA. What are the practical challenges
39:46
involved then in getting patients the dental
39:48
care they might need, particularly those facing
39:50
disparities? Referrals for dental care are often
39:52
challenging, precisely due to the barriers we
39:54
just mentioned. Insurance coverage issues, the
39:57
direct cost of treatment, simply lack of access
40:00
to dental providers, particularly for patients
40:02
in underserved areas. The sources suggest social
40:05
workers or nurse navigators can play a crucial
40:08
role here, guiding patients to available resources.
40:12
They mention options like free dental clinics,
40:14
clinics affiliated with academic centers or dental
40:16
schools, government or local health department
40:19
resources, or utilizing online tools like the
40:23
Neighborhood Navigator website, which helps locate
40:25
local resources for various social needs, including
40:28
dental care. For smaller orthopedic practices,
40:31
or those in rural areas, developing their own
40:34
network of local dental providers willing and
40:36
able to see these patients quickly is essential.
40:39
Crucially, the authors explicitly raise an ethical
40:41
consideration related to this ambiguity. Given
40:44
the lack of strong evidence definitively proving
40:46
the necessity and benefit of routine pre -op
40:49
dental extraction for preventing PGI, they argue
40:52
that creating another absolute requirement or
40:54
hard stop like mandatory dental clearance might
40:57
not be warranted. They highlight that inflexible
40:59
criteria, like strict BMI limits, have already
41:02
adversely affected access to TJA for disadvantaged
41:06
populations. Their concern is that imposing an
41:09
uncertain requirement like mandatory dental clearance,
41:12
especially given the access barriers to dental
41:14
care for vulnerable groups, could inadvertently
41:16
create yet another hurdle, one that disproportionately
41:19
impacts these patients, potentially leading to
41:21
unnecessary surgical delays or cancellations
41:23
and widening existing disparities in access.
41:27
That powerfully mirrors the point about strict
41:29
cutoffs we discussed earlier with smoking and
41:31
BMI. It seems the focus needs to be on improving
41:34
access to dental care for overall health rather
41:36
than potentially using it as an arbitrary barrier
41:39
to surgery. Precisely. It underscores the need
41:41
for integrated health systems where patients
41:43
can access comprehensive care rather than encountering
41:46
silos that become obstacles. Let's look at two
41:49
infectious diseases often linked to stigma, HIV
41:52
and hepatitis C. How do these conditions factor
41:55
into the TJA landscape, and are there disparities
41:58
and prevalence here, too? These are important
42:00
conditions to address, not least because they
42:02
can carry significant social stigma, which, as
42:05
the sources point out, can act as an additional
42:07
barrier for patients seeking health care, including
42:09
surgery. The sources state that an estimated
42:12
1 .2 million Americans are living with HIV. Sadly,
42:16
African Americans and Hispanics account for the
42:18
largest proportion of both new diagnoses and
42:21
people living with HIV. For hepatitis C, rates
42:24
have been increasing, affecting an estimated
42:26
five to seven million individuals in the U .S.
42:28
Over half of those infected are unaware of their
42:31
status. Hepatitis C infections are highest in
42:34
African Americans, and chronic infection rates
42:36
highest in foreign -born individuals. So, clear
42:39
and significant disparities exist in both HIV
42:41
and hepatitis C prevalence, and both can carry
42:43
stigma. What are the surgical implications for
42:46
a patient with HIV or hepatitis C needing a joint
42:49
replacement? For HIV -positive patients, particularly
42:52
those with other complex comorbidities, the sources
42:55
note they are at an elevated risk for post -op
42:57
complications. Historically, HIV was associated
43:00
with very high infection rates after TJA. But
43:04
the authors are careful to point out that many
43:05
early studies were confounded. A large proportion
43:08
of HIV -positive patients also had a history
43:10
of intravenous drug use, itself a major risk
43:13
factor for infection. Right, a confounding factor.
43:16
However, the recent evidence cited in the article
43:18
provides a more nuanced picture. It suggests
43:20
that with proper medical management, using effective
43:22
antiretroviral therapy, ARVs, to control a virus,
43:26
and with diligent optimization of any associated
43:28
comorbidities, the risk of PJI in HIV -positive
43:32
patients is only slightly elevated, or may even
43:35
be similar to the general population. This is
43:38
particularly true if their immune parameters,
43:39
specifically a CD4 count above 200 and an undetectable
43:43
or very low viral load, are well managed. The
43:46
article does add a caution, however. Achieving
43:48
these optimal immune parameters isn't always
43:50
possible for every patient, and the direct evidence
43:53
proving that optimizing these specific lab values
43:55
definitively reduces TJA complications isn't
43:58
uniformly strong. Interestingly, the article
44:00
also points out that the very ARV medications
44:02
used to treat HIV are associated with the significantly
44:05
increased incidence of hip osteonecrosis, up
44:08
to 100 times higher in some reports. This directly
44:11
contributes to the demand for total hip arthroplasty
44:13
within the HIV -positive patient population.
44:16
For hepatitis C, the sources state that infection
44:18
also increases the risk of surgical complications
44:20
after TJA. But importantly, they note that these
44:23
increased risks tend to normalize when patients
44:25
are successfully screened and treated for hepatitis
44:28
C before their surgery. That's a crucial distinction.
44:31
Treatment normalizes the surgical risk for hepatitis
44:33
C. That's really positive. What about optimization
44:36
strategies for both HIV and hepatitis C patients
44:39
preparing for TJA? Preoperative screening is
44:42
highlighted as a key opportunity to identify
44:44
patients unaware of their status. Especially
44:46
since CDC guidelines recommend routine HIV screening
44:49
for adults 13 -64 and screening for hep C in
44:53
all adults 18 -plus at least once, HHS guidelines
44:56
also recommend testing HCV -positive patients
44:58
for HIV. Once identified, optimization requires
45:02
a comprehensive multidisciplinary strategy. This
45:05
focuses on ensuring the patient's HIV treatment
45:07
is optimized, reducing viral load, improving
45:09
immune function, and that hepatitis C is treated
45:12
and cured if possible. while also rigorously
45:15
managing any associated comorbidities, which
45:17
would be complex, for example liver disease and
45:19
HCV, or cardiovascular renal issues, often seen
45:21
with long -term ARVs. The sources identify dedicated
45:24
HIV clinics, often run by infectious disease
45:27
services, and integrated care models, like multidisciplinary
45:30
teams co -located within community health centers,
45:32
as being vital for effectively managing these
45:33
patients. These models often include skilled
45:36
care coordinators or patient navigators. They're
45:38
absolutely crucial for linking patients to ongoing
45:40
infectious disease care, ensuring access to and
45:42
compliance with treatment regimens and addressing
45:44
complex psychosocial factors that might act as
45:47
barriers, missed appointments, adherence issues,
45:50
social support challenges. That support network
45:53
seems key again. Absolutely. The article also
45:56
mentions valuable resources for clinicians seeking
45:58
guidance, like the Hepatitis Technical Assistance
46:00
Center, Hepatitis C online course, and the NCCC
46:04
Consultation Service at UCSF. That integrated
46:07
approach, recognizing the medical complexity
46:09
and the social factors like stigma, sounds absolutely
46:12
essential. Let's move on to mental health, another
46:15
complex area. Mental illness is a widespread
46:17
health issue. affects approximately 20 .6 % of
46:20
U .S. adults in any given year. High lifetime
46:22
prevalence rates for depression, 17%, and anxiety
46:26
disorders, 29%. The sources note women tend to
46:29
be more affected than men. And how does this
46:31
relate back to disparities? Is there a link?
46:34
Again, the sources draw a clear connection. They
46:37
state that racial and ethnic minorities experience
46:39
disproportionate levels of discrimination, which
46:42
is linked to higher rates of depression, anxiety,
46:44
general psychological distress. African Americans
46:47
in particular are identified as being more likely
46:49
to experience chronic depression, have more severe
46:52
symptoms when depressed, and face significant
46:54
challenges accessing mental health treatment.
46:57
Lower socioeconomic status is also consistently
46:59
associated with worse mental health outcomes.
47:02
How does a patient's preoperative mental health
47:04
influence their experience and outcomes related
47:06
to TJA surgery? Does it make a difference? The
47:09
sources indicate that a patient's mental health
47:12
status going into surgery does correlate with
47:15
outcomes. although the relationship is nuanced.
47:18
Better preoperative mental health is generally
47:20
associated with improved post -op outcomes. Conversely,
47:25
poor preoperative mental health is linked to
47:27
worse functional outcomes, how well they can
47:29
move, perform daily activities at both one year
47:32
and five years after TJA. However, and this is
47:35
an important distinction highlighted, patients
47:37
with poor pre -op mental health still demonstrate
47:40
equal improvement in their functional outcomes
47:42
after surgery compared to those with better mental
47:45
health. Ah, okay, so they still improve just
47:47
maybe from a lower starting point. Exactly. It
47:50
suggests the surgery itself is equally effective
47:53
at improving function, regardless of baseline
47:55
mental health, though the starting point and
47:58
potentially the peak level achieved might differ.
48:01
Mental health disorders are also associated with
48:03
specific post -op complications. Psychosis, anemia,
48:07
infection, pulmonary embolism. They're linked
48:10
to prolonged hospital stays, higher rates of
48:12
non -routine discharge, like needing skilled
48:14
nursing, higher overall hospital charges. Interestingly,
48:19
the sources note that mental health scores, particularly
48:22
related to depression, often improve significantly
48:25
after TJA. Really? Yes. The authors hypothesize
48:28
this improvement is likely a direct result of
48:30
the significant reduction in physical disability
48:31
and pain afforded by the successful joint replacement
48:34
surgery. That makes intuitive sense, doesn't
48:36
it? Reducing chronic pain, restoring mobility
48:38
would likely have a positive impact on mood,
48:40
overall well -being. What about strategies for
48:43
optimizing mental health in the preoperative
48:45
period? Is much being done? The survey of orthopedic
48:47
institutions revealed, similar to many other
48:50
areas, wide variability. A general lack of consistent,
48:54
structured, preoperative mental health screening.
48:56
One institution reported using the Promise 10
48:58
tool, a standardized questionnaire. But most
49:01
didn't have a formal screening process in place,
49:04
although they often recognized this as a significant
49:07
gap. While studies clearly show an association
49:10
between pre -op mental health and outcomes, the
49:12
sources state they couldn't identify clear research,
49:15
specifically demonstrating the efficacy of structured
49:17
pre -op mental health optimization programs specifically
49:20
for TJA patients in improving surgical outcomes.
49:24
However, based on general medical principles,
49:26
treating identifiable poor mental health before
49:28
an elective surgery like TJA seems logically
49:31
beneficial, and should ideally be managed probably
49:34
by the patient's primary care physician or another
49:36
non -orthopedic provider. Addressing depression
49:39
or anxiety takes time. Antidepressants, for example,
49:42
can take four to six weeks for acute improvement,
49:44
potentially four to six months or longer for
49:46
chronic depression. Building a trusting relationship
49:48
with a primary care provider is highlighted as
49:50
particularly important, especially for what the
49:53
sources call low activation patients, those facing
49:56
greater challenges engaging with health care.
49:59
Routine mental health screening within primary
50:01
care allows for earlier identification and treatment,
50:04
potentially impacting readiness for future TJA.
50:06
The sources also suggest orthosurgeons should
50:08
consider screening if they suspect issues aren't
50:11
being addressed by the PCP. Finally, The articles
50:14
point out a lack of formalized processes for
50:17
assessing a patient's social support system across
50:19
institutions, despite it being universally evaluated
50:22
informally. This suggests a need for validated
50:25
tools or structured approaches to better understand
50:27
a patient's support network crucial for mental
50:29
well -being and post -up recovery. So a recognized
50:33
need for better screening and optimization, perhaps
50:36
integrated more effectively with primary care.
50:38
while acknowledging that the surgery itself can
50:40
offer a significant mental health benefit by
50:43
alleviating physical pain. Finally, let's tackle
50:45
housing insecurity. This feels like such a fundamental
50:48
social determinant. It could present a massive,
50:51
almost overwhelming barrier to accessing elective
50:53
surgery. It absolutely is a fundamental social
50:56
determinant. And the sources are quite direct
50:58
about its impact. Housing insecurity, lack of
51:01
stable, safe, affordable housing affects a significant
51:04
portion of the U .S. population, estimated 10
51:07
-15%. And it disproportionately impacts low -income
51:10
individuals, racial minorities, unmarried people.
51:13
And the sources describe a kind of cyclic relationship
51:15
between health conditions like osteoarthritis
51:18
and housing insecurity. Yes, they describe it
51:20
as an inexorable, cyclic, often structurally
51:24
reinforced relationship. The chronic pain, disability
51:27
from severe osteoarthritis, directly affect a
51:30
person's ability to work, earn income, which
51:33
impacts their ability to secure, maintain stable
51:36
housing. Conversely, chronic illness generally
51:38
can make it harder to maintain housing, and housing
51:41
instability itself creates significant barriers
51:43
to accessing consistent health care following
51:46
treatment plans, ultimately negatively impacting
51:49
overall health status. This raises a crucial
51:52
ethical and practical question which the source
51:54
directly addresses. Should housing insecurity
51:57
be allowed to be a barrier to necessary surgery?
52:00
And the answer, unequivocally stated in the sources,
52:03
is no. They state forcefully that while housing
52:05
insecurity is currently an imposed barrier to
52:08
surgery for many patients, based on traditional
52:10
discharge planning assumptions, it absolutely
52:13
should not be. That's a powerful statement. What
52:15
kind of creative solutions are mentioned, then,
52:17
to address this barrier and ensure patients can
52:19
still access TJA even if they lack stable housing?
52:22
The sources list several examples of creative,
52:25
compassionate solutions that exist or could be
52:27
implemented. These include advocating for insurance
52:29
company waivers to cover temporary post -discharge
52:32
accommodation. leveraging existing community
52:35
resources churches, charities like Meals on Wheels
52:38
providing support, utilizing halfway houses,
52:41
transitional living facilities, or even providing
52:44
temporary housing like covering a short hotel
52:46
stay for initial recovery. The key message is
52:49
that solutions do exist. Healthcare systems providers
52:52
need to actively identify and utilize them rather
52:55
than letting housing status become a reason to
52:57
deny or delay necessary surgery. However, the
53:01
survey of the seven orthopedic institutions highlighted
53:03
a significant gap in current practice here. Only
53:06
two out of the seven surveyed institutions reported
53:09
actively screening for housing insecurity in
53:11
their preoperative assessment process. Only two
53:13
out of seven. Yes. This indicates this critical
53:16
social determinant is being widely missed as
53:18
a potential barrier to care. likely leading to
53:20
unnecessary exclusion of patients. Wow, that
53:23
statistic really underscores how much this fundamental
53:25
social factor is overlooked in standard preoperative
53:28
pathways. It does. And this ties directly into
53:30
the broader discussion around discharge planning.
53:33
The sources strongly emphasize that robust discharge
53:36
planning must be a critical, formalized part
53:38
of the preoperative optimization pathway for
53:41
all patients. But it's particularly vital for
53:43
vulnerable populations who may lack traditional
53:45
home support or stable housing. Care managers
53:49
integrated into the pre -op team need to proactively
53:52
identify potential family or community resources
53:54
before surgery to build a detailed, feasible
53:58
discharge plan. This plan might involve arranging
54:01
post -op rehab in a skilled nursing facility,
54:04
coordinating home health services, facilitating
54:06
outpatient therapy. Identifying resource availability
54:09
and potential barriers like housing and security
54:11
early allows the care team to address these challenges
54:13
proactively. collaborating with community or
54:16
hospital -based resources to ensure a safe, supported
54:18
transition. So instead of letting a lack of stable
54:21
housing be an insurmountable barrier that prevents
54:23
surgery, the approach should be identify it early,
54:26
proactively plan around it with creative solutions
54:28
and robust support systems. Exactly. It requires
54:30
foresight, a commitment to problem -solving,
54:33
viewing it as a solvable challenge requiring
54:36
resources and coordination, rather than an excuse
54:39
to deny access to a life -changing procedure.
54:42
This discussion really brings us full circle,
54:45
doesn't it? We've explored this incredibly complex,
54:47
interconnected web of factors from medical comorbidities
54:51
like cardiovascular disease, CKD, anemia, to
54:55
behavioral factors like smoking, alcohol substance
54:58
use, infectious diseases like HIV, Hep C, mental
55:02
health, and fundamental social determinants like
55:05
access to oral health care and housing insecurity.
55:08
The findings from these JOGAOS articles, particularly
55:11
that survey data, reveal wide variability in
55:14
how these factors are addressed, often a significant
55:16
lack of structured, consistent approaches, especially
55:19
concerning the behavioral and social determinants.
55:21
That's the clear takeaway from the data presented
55:23
across these articles, yes. While orthopedic
55:25
teams recognize some of these risks clinically,
55:28
there's significant room for improvement in standardizing
55:30
and implementing comprehensive pre -optimization
55:33
programs that truly capture this complexity.
55:35
and they consistently reinforce that core message
55:38
introduced at the beginning of the series. Preoperative
55:41
optimization can indeed reduce complications
55:43
and improve access to TJA for underserved patients,
55:46
but this positive impact is contingent on how
55:49
that optimization is approached. Precisely. They
55:51
draw a clear contrast between supportive, patient
55:55
-centered optimization and the use of strict,
55:57
inflexible preoperative cutoffs like rigid BMI
56:00
limits, mandatory unsupported smoking cessation,
56:04
and potentially ill -defined dental clearance
56:06
requirements. They argue these inflexible criteria
56:09
particularly when implemented without adequate
56:12
support for patients to address the underlying
56:13
issues disproportionately affect minority and
56:16
indigent populations. Their concern, supported
56:19
by evidence on outcomes related to BMI cutoffs,
56:22
is that these rigid requirements can be unethical.
56:24
They risk leading to cherry -picking of healthier,
56:27
lower -risk patients, thereby exacerbating existing
56:30
health disparities rather than reducing them.
56:32
So the recommended approach isn't about raising
56:34
the bar higher to exclude patients, is it? It's
56:37
about building a more accessible pathway to health
56:39
for everyone. Yes. The sources strongly advocate
56:43
for flexible programs that truly prioritize the
56:46
individual patient's perspective. their unique
56:48
challenges, the potential benefit they can gain
56:51
from the surgery and the optimization process.
56:54
They highlight essential components for such
56:56
programs to be successful, particularly for vulnerable
56:59
populations. appropriate assistance from dedicated
57:02
nurse navigators, integrated access to a range
57:05
of specialists. This means established referral
57:08
pathways, collaborative relationships with services
57:10
focused on weight management, smoking cessation,
57:13
endocrinology, infectious disease, addiction
57:16
services, psychiatry, social work, all those
57:18
connections. These support systems are deemed
57:20
absolutely vital for helping patients effectively
57:23
address their modifiable risk factors. The argument
57:26
is that well -designed programs with this kind
57:28
of comprehensive support can benefit all patients.
57:31
But crucially, they have the potential to significantly
57:34
decrease health inequities by providing the necessary
57:36
resources for patients who face systemic barriers
57:39
to achieve surgical readiness. That paints a
57:41
powerful vision for healthcare, doesn't it? Where
57:44
optimization is about empowering patients, building
57:47
bridges to care, rather than creating walls based
57:49
on pre -existing health or social challenges.
57:52
It fundamentally shifts the paradigm. from one
57:55
of exclusion based on risk factors to one of
57:58
inclusion through facilitated health improvement
58:01
and equitable support. That makes so much sense.
58:04
And it's such a crucial perspective on how we
58:06
deliver care. We've covered a vast amount of
58:09
ground here, revealing just how deeply interconnected
58:12
a patient's health, their social circumstances,
58:15
access to care are when it comes to something
58:17
like life -changing joint replacement surgery.
58:20
Let's wrap up with a quick lightning round based
58:22
on what we've discussed. Ready when you are.
58:24
If you could recommend one key area for orthopedic
58:27
teams or healthcare systems more broadly to begin
58:30
or significantly improve screening and support
58:33
based on the findings in this material, what
58:35
would it be? Hmm. That's a tough one. But given
58:38
the survey data showing only two out of seven
58:40
institutions actively screened for it, I would
58:43
argue housing and security is a critical, often
58:46
missed area needing immediate attention. precisely
58:49
because the sources state it should not be an
58:52
imposed barrier. Proactive screening connecting
58:55
patients with available resources can make a
58:57
significant difference. That's a powerful choice,
59:00
yes. Is there a single relatively simple low
59:04
-cost intervention highlighted in the sources
59:06
that could have a significant impact, particularly
59:08
in these underserved groups? Yes, I think iron
59:11
supplementation for patients identified with
59:13
iron deficiency anemia, it's very straightforward,
59:15
inexpensive. Correcting anemia preoperatively
59:17
has clear benefits, reducing transfusion needs,
59:20
improving outcomes. It directly addresses a risk
59:23
factor that's treatable with minimal resources.
59:25
Even brief smoking or alcohol cessation counseling
59:28
sessions, while maybe not achieving full abstinence
59:30
alone can be considered low -cost interventions
59:33
that can yield some benefit. Good point. And
59:36
finally, what's one specific resource mentioned
59:38
in these articles that listeners, perhaps clinicians,
59:42
administrators, patient advocates could explore
59:43
further to help address some of these challenges?
59:47
Well, the Neighborhood Navigator website mentioned
59:49
for finding dental resources is actually a broader
59:52
tool. for exploring local social determinants
59:55
of health resources, food banks, housing assistance,
59:59
transport options, more. That can be very useful.
1:00:01
For clinicians specifically, resources like the
1:00:04
Hepatitis C online course or the NCC UCSF consultation
1:00:08
service for complex infectious disease cases
1:00:10
are valuable tools for improving clinical management.
1:00:13
Excellent suggestions. So to summarize the key
1:00:16
actionable takeaways from this deep dive into
1:00:18
the JOS movement is life series. These sources
1:00:22
lay bare a complex interconnected web. health
1:00:24
conditions, social determinants from cardiovascular,
1:00:27
kidney disease to substance use, oral health
1:00:29
access, mental health, housing and security,
1:00:31
all profoundly impacting not just TJA outcomes,
1:00:34
but a patient's fundamental access to this needed
1:00:36
surgery. And crucially, they powerfully demonstrate
1:00:39
how these factors disproportionately affect underserved
1:00:42
communities, minorities, often as a direct consequence
1:00:46
of systemic issues. The burden of discrimination
1:00:49
historical disparities and access to quality
1:00:51
primary care and resources over a lifetime. The
1:00:54
takeaway isn't that these patients are Too risky
1:00:57
for surgery, is it? Instead, the sources argue
1:01:00
that while preoperative optimization is absolutely
1:01:02
critical for safety and success, how it's approached
1:01:05
matters immensely. They issue a strong caution.
1:01:09
Strict, inflexible cutoffs for modifiable risk
1:01:11
factors implemented without adequate support
1:01:14
systems for patients to address these issues
1:01:16
can actually worsen health disparities, excluding
1:01:18
patients who may benefit most but face the greatest
1:01:20
systemic barriers. The path forward, as recommended
1:01:23
in these articles, involves implementing comprehensive
1:01:25
flexible, truly patient -centered programs. These
1:01:29
must include dedicated support mechanisms, particularly
1:01:32
the invaluable assistance of nurse navigators
1:01:35
and integrated access to a range of specialists.
1:01:38
This provides patients with the resources and
1:01:40
guidance needed to successfully address their
1:01:43
modifiable risk factors. This is the approach
1:01:45
that can lead to both better outcomes for individual
1:01:47
patients and, critically, more equitable access
1:01:50
to life -changing surgery for everyone. It's
1:01:53
about shifting the focus, isn't it? From gatekeeping
1:01:55
to guidance. From barriers to bridges. Thank
1:01:58
you so much for guiding us through this incredibly
1:02:01
important body of work. It really highlights
1:02:03
how essential it is for the orthopedic community,
1:02:06
and indeed all healthcare providers, to look
1:02:08
beyond the specific medical procedure. To truly
1:02:11
embrace the complex reality of our patients'
1:02:14
lives, the systemic factor shaping their health
1:02:17
journeys, if we are to move towards genuine health
1:02:20
equity. If you found this deep dive valuable,
1:02:23
please do take a moment to rate and share it,
1:02:25
particularly with colleagues in healthcare who
1:02:27
might benefit from understanding these critical
1:02:29
issues in patient care and equitable access.
1:02:32
It's been a genuine pleasure discussing this
1:02:34
vital topic and the insights these articles provide.
1:02:36
And that's our deep dive for today. Join us next
1:02:39
time on the deep dive.