Interpreter use was not associated with regional anesthesia utilization for total joint arthroplasty

Description #

Documented interpreter use was not significantly associated with regional anesthesia utilization (Table; "Interpreter used" P = .58). Interpreter use was rare overall: among the 707 non-RA patients, 10 (1.4%) had an interpreter documented; among the 58,211 RA patients, 980 (1.7%) did. A parallel "Interpreter needed" variable was likewise non-significant (P = .1654). Because interpreter use marks the LEP subgroup, this null is consistent with the primary language finding.

"Interpreter used … Yes … 10 … 1.4 … 980 … 1.7 … No … 697 … 98.6 … 57,231 … 98.3 … .58" (Sabra, 2025, p. 994, Table)

"Principal variables were primary language (English versus LEP), use of translation services, and translation modality (in-person, video, or telephone translation) as documented on the EMR." (Sabra, 2025, p. 993)

Methods Context #

What? #ⓘ

The observable: regional anesthesia utilization compared by whether a language interpreter / translation service was documented as used for the patient.

"Additional variables included … use of translation services, and translation modality." (Sabra, 2025, p. 993)

How? #ⓘ

Univariate χ² association between documented interpreter use and RA use, from the Epic EMR search of THR/TKR patients 2016–2023.

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

Who? #ⓘ

The full HSS cohort of 58,918 THR/TKR patients (2016–2023); only ~990 (1.7%) had any interpreter use documented.

"The requirement for written informed consent was waived by the IRB. An Epic electronic medical record (EMR) search was conducted for all patients undergoing THR or TKR between January 1, 2016, and December 31, 2023." (Sabra, 2025, p. 993)

Other Notes #

Table-only association (not discussed in the Results narrative). The very small number of interpreter-using patients limits power to detect any difference.

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.)