Are Body Mass Index (BMI), diabetes, and smoking cutoffs creating racial, ethnic, gender, or age disparities in patient eligibility for Total Ankle Arthroplasty?

Abstract

Background: The rising prevalence of obesity, diabetes, and smoking among American adults has disproportionately affected female, Black, and younger patients. The purpose of this study was to evaluate for disparity in patient eligibility for Total Ankle Arthroplasty (TAA) based on race, ethnicity, gender, and age by applying Body Mass Index (BMI), smoking, and diabetes criteria to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Methods: Patients in the ACS-NSQIP database who underwent TAA from 2011- 2020 were retrospectively reviewed. BMI cut-offs of <50kg/m², <45kg/m², <40kg/m², <35kg/m², diabetes, and smoking criteria were then applied. The eligibility rate for TAA was examined for each BMI cut-off, diabetes, and smoking; findings were stratified by race, ethnicity, gender, and age. Independent T-tests, Chi-squared tests, and Fisher’s exact tests were performed to compare differences at an α = 0.05. Results: 1215/1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cut-off of <35kg/m² (p=0.004). In contrast, Asian American/Pacific Islander patients had higher rates of eligibility at the BMI cut-offs of <35kg/m² (p=0.033) and <40kg/m² (p=0.039). Black patients also had lower eligibility rates after diabetes (p=0.042) and smoking (p=0.008) criteria were applied. Whereas, white non-Hispanic patients had disproportionately higher rates of eligibility after the diabetes criterion was applied (p=0.04). Females had lower eligibility rates across all BMI cut-offs (p<0.05 for all). Younger patients had lower eligibility rates across all BMI cut-offs (p<0.05 for all) and smoking (57 ± 10, p<0.001). Conclusion: Stringent BMI cut-offs, diabetes, and smoking criteria may disproportionately disqualify women, Black, and younger patients from receiving Total Ankle Arthroplasty. This data suggests that current eligibility criteria may exacerbate disparity in access to arthroplasty care for already vulnerable populations.