Preferred language was not associated with regional anesthesia utilization on univariate analysis for total joint arthroplasty

Description #

On univariate comparison, regional anesthesia (RA) utilization did not differ significantly between English-speaking and limited-English-proficiency (LEP) patients undergoing total joint arthroplasty (Table; preferred-language P = .3479). Among the 707 patients who did NOT receive RA, 98.2% preferred English and 1.8% preferred another language; among the 58,211 who DID receive RA, 97.6% preferred English and 2.4% another language. English speakers accounted for 57,520 (97.6%) of the cohort. Univariate group differences WERE found for age, insurance, year of surgery, ASA class, and surgical disposition — but not for preferred language.

"When comparing RA use between English-speaking and LEP patients, we found no significant difference in RA utilization based on preferred language. We found group differences for age, insurance, year of surgery, ASA class, and surgical disposition." (Sabra, 2025, p. 995)

"Preferred language … English … Other … P value .3479" (Sabra, 2025, p. 994, Table)

Methods Context #

What? #ⓘ

The observable: regional anesthesia (neuraxial or peripheral nerve block) utilization, compared across preferred language (English versus LEP).

"The primary outcome is RA (neuraxial/peripheral nerve block) utilization for English versus LEP patients." (Sabra, 2025, p. 993)

How? #ⓘ

Univariate association testing between RA use and preferred language using Mann-Whitney U tests and χ² tests, on an Epic EMR search of all THR/TKR patients over 2016–2023 (STROBE-adherent retrospective design).

"Univariate associations between RA use and all available variables including preferred language were assessed using Mann-Whitney U tests and χ² tests." (Sabra, 2025, p. 993)

Who? #ⓘ

Patients aged >18 presenting for primary, elective, unilateral total hip (THR) or total knee replacement (TKR) at the Hospital for Special Surgery (HSS), New York, between 1 Jan 2016 and 31 Dec 2023; 58,918 identified, of whom 58,211 received RA. Revision, bilateral, nonelective/urgent, trauma, prior-spine-surgery, and active-infection cases were excluded.

"Inclusion criteria were patients aged greater than 18 years presenting for primary, elective, unilateral THR, or TKR between January 1, 2016 and December 31, 2023." (Sabra, 2025, p. 993)

Other Notes #

This is a null univariate result. Only 13 LEP ("Other"-language) patients did not receive RA (out of ~1,398 LEP patients), so the non-RA LEP cell is very small — see qualifying caveats on ceiling effect and power.

Caveats #

• Retrospective single-institution EMR study with provider-bias variability and unmeasured cognitive impairment The findings come from a single-institution, retrospective EMR-based study at one specialized orthopedic hospital (HSS), which limits generalizability to centers with different patient populations, payer mixes, and RA practices. The authors also note variability in provider bias, and that they could not exclude patients with cognitive impairment because that variable was unavailable in the record — a potential uncontrolled confounder of both language documentation and anesthetic decision-making. Interpreter use and modality were captured only as documented in the EMR, which may undercount actual language-service use.
• Underpowered to detect the small observed language effect despite large sample (post hoc power) Despite the large overall sample (58,918 patients), the study is by the authors' own post hoc assessment underpowered to detect the small, non-significant language effect it observed. The design targets clinically meaningful differences of ≥2%; a true difference smaller than that (or concentrated in the tiny LEP subgroup) could be overlooked. This is the central interpretive caveat on all of the null language findings: absence of a detected association is not evidence of no association. The authors caution the results should be interpreted cautiously and note that post hoc power calculations are not recommended for definitive conclusions.
• Near-universal regional anesthesia creates a ceiling effect with only 13 non-RA LEP patients [Inferred:] Because regional anesthesia was near-universal at this institution (98.8% of 58,918 patients), the "did not receive RA" outcome group is only 707 patients, and the LEP patients within it number just 13. With so few LEP non-RA events, there is almost no outcome variance in which a language-based disparity could be detected — a ceiling/floor effect that limits both the univariate and adjusted analyses regardless of the total sample size. The null language association is therefore weak evidence of true equivalence and may not transfer to institutions where RA is not already the default. (This is my inference from the Table's cell counts, complementary to the authors' own power caveat.)