Background

Unplanned returns to the emergency department (ED) and readmission rates following orthopaedic surgery are important markers for quality of care. A recent quality improvement project at Duke Health revealed that Black patients were more likely to present to the ED after orthopaedic surgery without a difference in readmission rates compared to white patients. 

While a return to the ED may be appropriate in the case of surgical complications, it can also represent a lapse in quality or inadequate discharge counseling, especially when the patient doesn’t need to be readmitted to the hospital. Furthermore, these return visits are costly to both patients and the healthcare system.
This data suggests an opportunity for an intervention that mitigates a racial disparity in unplanned returns to the ED. 

Project Description

Building on the work of the 2023-2024 team, this project team will characterize clinical details for return to the ED within 30 to 90 days after orthopaedic surgery, and adjust clinical practice and discharge counseling in order to help combat any underlying racial disparity.  

Team members will study deidentified medical records and demographic data from adults who underwent orthopedic surgery from 2017-2021 in the Duke University Health System and presented to the ED within 30 to 90 days postoperatively (approximately 400 patients total). Chief complaints in the ED will be collected and categorized. After examining demographic data (race, age, sex, ethnicity, zip code, financial class) and clinical data (patient history, type of surgery, complications, details of return to ED), the team will work to understand clinical drivers of disparity in ED return. 

Team members will analyze this data using several different approaches, including statistical tests that will be used to understand association of patient level variables with risk of return to the ED; machine learning to generate risk predictions of returns to the ED at the time of discharge; and focus groups with orthopaedic trauma patients, healthcare providers and community groups to identify common factors that are contributing to disparities in return to ED that aren’t represented well in clinical data.

While the data collection phase of the project will continue, the team will also move forward with designing, implementing and evaluating interventions for improving predischarge counseling or follow-up to help mitigate underlying drivers of disparities in ED return. In one intervention, patients will be able to enroll in focus groups and enhanced discharge counseling. Other patients will elect to be part of an intervention incorporating emerging technologies — a large language model-based service to improve access and enhance quality of postoperative care.

Anticipated Outputs

Manuscripts, posters and presentations; implementation of a patient AI chat tool for patient questions and concerns; updated anticipatory guidance for patients discharged from the orthopaedic trauma service

Student Opportunities

Ideally, this team will include 5 graduate and 5 undergraduate students from a variety of disciplines who are interested in addressing healthcare disparities. 

Team members will have the opportunity to work with orthopedic surgeons, nurses, case managers, physical therapists and emergency medicine physicians from Duke University Hospital. They will also engage with technology experts to see how to better harness emerging technologies to address disparities in a cost-effective manner. 

Team members will gain experience in quality improvement research — such as study design, survey collection, intervention implantation, quality metrics and manuscript writing — while working to address health disparities that affect the Durham community. Team members will engage in providing care or medical education, formulating health policy, participating in advocacy and promoting racial equity and social justice.

This project includes an optional summer component during Summer 2024 during which several students will conduct chart review and engage with patients and caregivers in clinics. Some team members may also have the opportunity to travel to an orthopaedic surgery conference.

Timing

Summer 2024 – Spring 2025

• Summer 2024 (optional): Continue chart review; engage with patients and caregivers in clinics; complete manuscript publication for disparities analysis efforts; present results at American Academy of Orthopaedic Surgery (AAOS) Annual Meeting 2024; begin implementing interventions after patient enrollment completed in Spring 2024
• Fall 2024: Continue implementing interventions; collect readmission data; conduct preliminary analysis; adjust interventions
• Spring 2025: Finish collecting intervention-associated data; complete analysis; publish results of intervention; present results at AAOS Annual Meeting 2025

Crediting

Academic credit available for fall and spring semesters; summer funding available

See earlier related team, Racial Disparities in Emergency Department Return After Orthopaedic Surgery (2023-2024).