We read the study titled “Evidence-based Perioperative Practice Utilization among Various Racial Populations—A Retrospective Cohort Trending Analysis of Lower Extremity Total Joint Arthroplasty Patients.” It included 3.4 million lower extremity arthroplasty patients from 2006 to 2021. The authors used these data to determine (1) whether utilization of standardized evidence-based perioperative practice increased during the study period, irrespective of race; (2) whether evidence-based perioperative practice was associated with decreased postoperative complications, mortality, and prolonged length of stay across racial groups; and (3) whether evidence-based perioperative practice was associated with a decrease in racial disparities for those postoperative outcomes. The authors found that, despite utilization of evidence-based perioperative practice, Black patients experienced higher rates of postoperative complications, mortality, and prolonged length of stay compared to White patients. Although evidence-based perioperative practice utilization increased during the study period and was found to decrease poorer outcomes for all races, Black patients still experienced worse outcomes than White patients in all outcomes despite evidence-based perioperative practice. Black patients were also less likely to receive evidence-based perioperative practice compared to White patients. The authors suggest that more research be done to explain (1) the reasons underlying the persistent disparity between Black and White patients despite implementation of evidence-based perioperative practice, (2) why implementation of evidence-based perioperative practice in Black populations lags behind White populations, and (3) why evidence-based perioperative practice affects Black and White patients differently.

We applaud the authors for examining the mechanisms that may explain disparities in perioperative medicine, particularly regarding the interplay between race and evidence-based perioperative practice. However, we would like to address the potential lack of fidelity of evidence-based perioperative practice. It is highly plausible that inadequate fidelity of evidence-based perioperative practice may partially explain the Black–White disparity. It has been shown that Black patients receive poorer quality of care, often in lower volume facilities, compared to White patients. This same lack of delivery of high-quality care to Black patients may also pervade evidence-based perioperative practice, meaning that although documented as high-quality evidence-based perioperative practice, the actual care provided may not be clinically adequate to yield the same improvement in outcomes. More studies may also be needed to determine the applicability of evidence-based perioperative practice strategies to Black (and other) communities underrepresented in clinical research. Previous studies show that evidence-based perioperative practice and other interventions effective in White patient populations may not be as effective in Black and other populations. This reduced effectiveness may be due to lack of fidelity and/or underrepresentation of these groups in studies examining the efficacy of evidence-based perioperative practice. Addressing underrepresentation should reduce the likelihood of interventions not being as effective in segments of the population. Additionally, stratifying data and conducting sensitivity analyses to ensure the majority group is not responsible for improved outcomes with evidence-based perioperative practice are also necessary (i.e., ensuring a health equity lens). Consequently, different or adaptation of existing interventions may be needed to improve postoperative outcomes more effectively in Black and other underrepresented communities (i.e., female sex, low socioeconomic status, sexual and gender minorities, individuals with limited English proficiency). These racial differences may help to explain why the Black–White disparity increases with evidence-based perioperative practice utilization in the present study. We suggest further studies of the fidelity of evidence-based perioperative practice delivered to Black patients compared to other groups, beginning with studies on multimodal anesthesia and tranexamic acid use as these are the most highly recommended perioperative interventions for lower joint arthroplasty patients. 

Moreover, we would like to emphasize the need for studies to explain why Black patients (and other populations experiencing disparities) are less likely to receive evidence-based perioperative practice than White patients. Although the Black–White disparity persists despite evidence-based perioperative practice implementation, evidence-based perioperative practice was shown to improve all outcomes in all patients. Regardless of fidelity, Black patients derive some benefit from current evidence-based perioperative practice administration over nonadministration. Therefore, evidence-based perioperative practice should be implemented to at least the level of other racial groups in Black patients. We recommend studies to understand and mitigate factors preventing Black patients from receiving evidence-based perioperative practice to the same degree as other racial groups.

Last, since socioeconomic status was not included, we suggest further analyses to investigate how socioeconomic status influence outcomes with and without evidence-based perioperative practice. Socioeconomic status have been shown to independently influence rates of postoperative complications, mortality, and length of stay.  As socioeconomic status often intersects with race, this could partly explain the continued Black–White disparity in surgical outcomes despite evidence-based perioperative practice. Similar analyses need to be done to determine the influence of socioeconomic status on the responsiveness to evidence-based perioperative practice in various racial groups.

While we applaud the authors’ efforts, we believe that further research is needed to determine the fidelity of evidence-based perioperative practice delivered to Black patients and the reasons Black patients are less likely to receive evidence-based perioperative practice, and to examine the role of socioeconomic status in the race–evidence-based perioperative practice relationship.