1 Introduction

In 1985, the Heckler report was released and provided the first substantial examination of health inequality and healthcare disparities in the United States.¹ Since the publication of this report, increasing attention has been paid to health inequity and healthcare disparities. Clearly, an understanding of the interplay between race and ethnicity and the social forces that may impact a patient's outcome following medical or surgical intervention is critical to best serve a diverse patient population in an equitable fashion. A present example of this is the literature regarding COVID-19. Data published during the height of the COVID-19 pandemic described a mortality rate among minority patients disproportionate to their counterparts.¹ Similar findings have been reported across medical specialties.^2–6 This type of data allows researchers to identify disparities which can ultimately lead to policy changes that can positively impact inequities in health outcomes among vulnerable patient populations.

Clinical research is therefore the portal through which health disparities can be understood. Concerns have been raised regarding best practices for the inclusion of race and ethnicity as independent variables in medical research. The inclusion of these factors is on one hand essential in order to identify health inequities among various patient populations, as recommended by editorial boards of high-impact peer-reviewed journals.⁷ However, others have pointed out that the inclusion of race and ethnicity in medical research should be thoughtful and comprehensive in order to avoid potential negative impacts. Classifying patients based on race and ethnicity using oversimplified or myopic definitions of categories can lead to conclusions in medical research, and treatment algorithms recommended by professional societies, that can be counterproductive.⁸ Careful attention should be paid to the proper definition of categories of race and ethnicity that truly capture the diversity of the patients included in medical research.

Best practices for the inclusion of race and ethnicity in orthopedic research, and in shoulder literature in particular, have not received sufficient attention to this point. While there is a general understanding of the importance of issues surrounding diversity, equity, inclusion, and belonging among orthopedic professional societies, most of this attention has been focused on diversity among the community of surgeons and leadership. At least as much attention should be paid to an understanding of the patients receiving treatment for shoulder conditions, to assure that this care is provided in an equitable fashion. In the context of clinical research, this understanding should begin with the inclusion of race and ethnicity as independent factors that may, through an interplay with social determinants of healthcare, impact patients’ outcomes. This investigation will examine the current approach to the inclusion of race and ethnicity among frequently referenced shoulder surgery literature. Guidance for best practices for the inclusion of race and ethnicity in shoulder research will also be discussed.

2 Methods

3 Results

An initial literature search for “rotator cuff repair” resulted in 4554 articles while the initial search for “total shoulder arthroplasty” and “Bankart repair” yielded 3857 articles and 1232 articles, respectively. When the eligibility criteria of finding studies spanning from the year 2013–2022 were applied, the number of “rotator cuff repair” papers was reduced to 3,184, the number of “total shoulder arthroplasty” papers was reduced to 3,092, and the number of “Bankart repair” papers were reduced to 829. After a meticulous analysis of the papers' abstracts and results, the goal to find the top 20 most cited papers in rotator cuff repair,^9–28 the top 10 most cited papers in “total shoulder arthroplasty”^29–38 and “Bankart repair”^29,39–47 was achieved.

In the “rotator cuff repair” cohort of papers, there were 2 articles that mention race. Out of the 2 articles that mentioned race, neither included race appropriately using the JAMA Updated Guidance on Reporting of Race and Ethnicity in Medical and Science Journals. In the “Bankart repair” cohort of papers, each article lacked the mention of race among their patient population. The “total shoulder arthroplasty” manuscripts also did not include treatment of race and ethnicity in any way.

4 Conclusion

Race and ethnicity and other social determinants of health can be used to understand the source of healthcare disparities. Healthcare disparities are significant gaps in the standard of care in terms of health and health care across racial and ethnic groups.⁴⁸ The Heckler report provided initial evidence of the actualization of healthcare disparities. Since the catalytic Heckler report described healthcare disparities, the conversation surrounding this multifactorial construct has increased.¹ Both dating back 300+ years, race and ethnicity are fluid concepts packed with complexity.⁴⁹ Differential outcomes in clinical research based on these factors as independent variables can provide invaluable insight. Whittle et al. discovered the presence of racial differences in patients undergoing cardiac catheterization and other invasive cardiac procedures, concluding black patients undergoing invasive cardiac procedures less than white patients even in the absence of financial implications.⁶ The manner in which healthcare is provided by physicians and other clinicians can perhaps perpetuate healthcare disparities in many ways. Clinicians are not immune to implicit bias. Chapman et al. make the claim, pressured by time and uncertainty during diagnoses, physicians could lean toward unconscious stereotypes to produce “efficient” patient care decision-making.⁵⁰ This simply perpetuates and perhaps heightens the health disparities and healthcare inequalities already present. Efforts to achieve awareness of the downstream interplay of race and ethnicity and clinical outcomes are paramount to addressing health and healthcare inequalities. Perhaps the disparities and inequalities present in healthcare treatment algorithms are enabled in part due to the absence or inaccurate reporting of race and ethnicity in clinical research.

There have been many proposed approaches to best practices for the inclusion of race and ethnicity in clinical research. In some cases, treatment algorithms include parameters based on race and/or ethnicity, occasionally with the goal of assuring equitable care. In other cases, race and/or ethnicity are purposefully excluded with the intention of providing equitable care. White et al. and the University of Pittsburg Department of Critical Care Medicine released a policy document describing an algorithm used to determine how critical care resources that are scarce will be distributed in the case of public health emergencies.⁵¹ The report describes an algorithm for ranking patients in need of critical care in a color-coded priority group based on the highest predicted benefit from the critical care intervention. Williams et al. state, “colorblind” healthcare algorithms such as the one previously described rely on biased data based on racially objective studies and may perpetuate the racial and ethnic inequalities and disparities rooted in the treatment of a diverse patient population.⁵² Obermeyer et al. examine a focus on patients at high risk of severe illness, without consideration of race/ethnicity, in order to determine how healthcare resources would be allocated.⁵³ This blinded approach inadvertently established a system that favored white patients over black patients. This study suggests that the inclusion of race/ethnicity in clinical research and the development of algorithms is essential in order to sustain healthcare equality. While the public health literature supports the importance of considering social determinants of health to assure health and healthcare equity, consensus regarding the best practices for the inclusion of race and ethnicity in clinical research does not exist.

Unless a thoughtful and deliberate consideration of race and ethnicity is undertaken, their inclusion in clinical research can be a double-edged sword. Inadequate inclusion of race and ethnicity may overlook the impact race and ethnicity have on health outcomes; whereas inclusion using an oversimplified approach may not adequately portray the diversity of the patient population we treat. Kowalsky et al. argue that oversimplification of race and ethnicity-centered treatment can perpetuate fallacies.⁸ These fallacies can then contribute to implicit bias on behalf of clinicians, and ultimately negatively impact patient outcomes and exacerbate racial and ethnic disparities in health care. It is important to understand that race and ethnicity are social constructions devoid of biological or anatomic actualization.⁷ While accepting this truth, one must also recognize the relationship of race and ethnicity, through various social determinants of health, to health and the health care disparities that many patients face. Using oversimplified definitions of race and ethnicity in diagnostic or treatment decisions in isolation can be harmful to these patients who face health care disparities. In the practice of medicine, and in clinical research, a nuanced understanding of race and ethnicity should be considered, in concert with socioeconomic factors, sociodemographic factors, along with social determinants that impact patients’ health.⁷

The authors believe best practices for the inclusion of race and ethnicity in shoulder research should closely align to JAMA's Updated Guide on the Reporting of Race and Ethnicity in Medical and Science Journals, which encourages authors to clearly specify populations while eliminating the use of board racial and/or ethnic categories.⁷ This is suggested because reduce oversimplification and misrepresentation of diverse patient populations. Authors are also persuaded to take social and historical context into consideration when reporting data on race and ethnicity. By applying JAMA's updated guide on reporting race and ethnicity to shoulder surgery clinical research, the authors believe race and ethnicity should be considered in concert with social factors that could impact patient outcomes in our patient population. Manuscripts for orthopedic surgery research should include a description of methods that contains detailed categorization of race and ethnicity according to a comprehensive schema. In addition, the methods should specify whether the researcher or the patient identified their race and/or ethnicity, with self-identification by the patient strongly encouraged. By avoiding the phrase ‘minority’, researchers demonstrate an understanding of the implicit presence of a potential hierarchy among minorities and the majority as well as the negative impact of these terms on the validity of clinical research. When attempting to describe a patient's racial or ethnic demographics, avoid using racial and ethnic grouped terms such as ‘whites’, ‘blacks’, and ‘Hispanics’. Instead utilize individualistic descriptive phrases such as white male participants or black female participants. The authors believe race, when reported, should always be reported as an independent, non-dichotomous variable; showing an understanding of the potential variation in the patient-reported race on an individual level.

Some of the issues centering on the inclusion of race and ethnicity in medical research are the improper, misguided, or insufficient reports of race and ethnicity. In clinical research, race is viewed as a dichotomous variable. Race is in fact a non-dichotomous variable, because simple white and black options fail to encompass the wide variations of race identification present within given communities. This investigation concluded the vast majority of the most cited literature in shoulder surgery in the last 20 years (encompassing total shoulder arthroplasty, Bankart repair, and rotator cuff repair), did not adequately include race or ethnicity in their treatment of patient demographics. When race and/or ethnicity were mentioned, race was not described as a non-dichotomous variable, and rationale was not provided for the way in which race and/or ethnicity were documented within the study. An understanding of race and ethnicity as part of the landscape of social determinants of health is essential for understanding our patients and the health outcomes of our patients in clinical research and in practice. If documented correctly, reasonable, and fair conclusions could be drawn from the given results. However, if documented inadequately, racial and ethnic biases and inequalities may be harmfully perpetuated and reflected in the products of our clinical research and in the care we provide to our patient population.

Despite the frequent deficiencies in how race and ethnicity are documented, one cannot deny the impact of accurate reporting of race and ethnicity on outcomes in medical research. Deficiencies in reporting race and ethnicity range from suboptimal reporting to oversimplification to oversight and neglect. This not only impacts how we treat our patients but significant jeopardizes the validity of the findings of medical research. Despite the current study highlighting the reporting deficiencies in shoulder surgery research, the deficiencies are not limited to orthopedic surgery research. Ma et al. highlights a trend of suboptimal reporting of race and ethnicity in prolific medical journals such as Annals of Internal Medicine, JAMA, The Lancet, and the New England Journal of Medicine.⁵⁴ The study found that out of 1152 primary research articles between 1999 and 2003 in the above listed journals, assignment of race and ethnicity by self-report was only 13 % and only 16 % listed their rationale for collecting information on race and ethnicity.⁵⁴ The article points to the lack of a comprehensive reporting protocol or guideline being the reason for such deficits.⁵⁴ A study by Moore examined the inclusion, documentation, and analysis of race and ethnicity data in research published in the field of ophthalmology in 2019.⁵⁵ The study reveals shortcomings and inconsistencies in the reporting of race and ethnicity due to many studies fail to provide information or the use of terminology that is outdated.⁵⁵ Moore also points to the lack of a standardized protocol for reporting of race and ethnicity impacting the accuracy of the findings of studies and suggests that implementing standardized reporting practice would increase understanding of disparities in eye health outcomes.⁵⁵ Mitchel et al. highlights shortcomings in reporting practices of race and ethnicity breast cancer research, and how these shortcomings hinder the understanding of breast cancer disparity outcomes in different racial and ethnic groups.⁵⁶ The authors also emphasize the need for guidelines for reporting race and ethnicity along with the importance of accurate documentation and analysis of race and ethnicity data in breast cancer research.⁵⁶

The proper reporting of race and ethnicity in medical research is paramount in achieving health equity and addressing disparities. Albuelzam et al. sheds light on how important collecting and reporting accurate data on race and ethnicity is for healthcare policies and patient interventions that impact diverse patient populations.⁵⁷ The authors believe by collecting and reporting accurate data on race and ethnicity and by recognizing the influence of socioeconomic factors on health outcomes, clinical researchers can develop more effective strategies to promote healthcare equity for a diverse patient population. Cooper et al. underscores importance of considering race and ethnicity in biomedical and biological research.⁵⁸ Cooper argues, while acknowledging the social construct of race, race holds biological significance especially in the way we understand health disparities and certain genetic variations among diverse populations. By recognizing the role race plays in clinical research, researchers are then able to perform a more in-depth analysis of the health outcomes while facilitating the development of personalized approaches for our diverse patient populations. Leopold et al. examines the reporting of race and ethnicity data in orthopedic research and the complexities that are associated with it.⁵⁹ This study calls for the need for a more standardized approach to address inconsistencies in reporting are and ethnicity. In doing so, Leopold argues, the validity of findings of the studies are drastically improved. Each article highlights how critical accurate reporting of race and ethnicity is in medical research. By simply addressing the challenges associated with the proper reporting of race and ethnicity, clinical researchers can help march toward achieving health equity, regardless of racial and ethnic background. The purpose of the present study is to identify whether inadequacies in reporting race and ethnicity exist in shoulder research, as it does in other disciplines, and to provide a framework to develop a more systematic and effective approach for this reporting in orthopedic research moving forward.

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CRediT authorship contribution statement

Byron A. Ward: Formal analysis, Investigation, Data curation, Writing – original draft. Marc S. Kowalsky: Conceptualization, Methodology, Writing – review & editing, Supervision, Project administration.