Abstract
BACKGROUND
The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored.
OBJECTIVE
To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment.
DESIGN
Prospective, observational study.
PARTICIPANTS
African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics.
MAIN MEASURES
Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons’ notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment.
RESULTS
Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26–0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36–1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16–1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21–1.54, P = 0.27).
CONCLUSIONS
In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.
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References
DuBard CA, Yow A, Bostrom S, Attiah E, Griffith B, Lawrence W. Racial/ethnic differences in quality of care for North Carolina Medicaid recipients. N C Med J. 2009;70(2):96–101.
Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev. 2000;57(Suppl 1):218–235.
National Institute of Health. Consensus development conference statement: total knee replacement, 2003. http://consensus.nih.gov/2003/2003totalkneereplacement117html.htm.
Kane RL, Saleh KJ, Wilt TJ, et al. Total knee replacement. evidence report/technology assessment no. 86 (prepared by the Minnesota Evidence-based Practice Center, Minneapolis, MN). Rockville: Agency for Healthcare Research and Quality; 2003. AHRQ Publication No. 04-E0006-2.
NIH consensus conference: total hip replacement. NIH consensus development panel on total hip replacement. JAMA. 1995;273:1950–1956.
Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum. 1995;38(11):1141–1146.
Dieppe PA, Basler HD, Chard J, et al. Knee replacement surgery for osteoarthritis: effectiveness, practice variations, indications, and possible determinants of utilization. Rheumatology. 1999;38:73–83.
Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health. 1993;83(7):948–954.
Baron BJ, Barrett J, Katz JN, Liang MH. Total hip arthroplasty: use and select complications in the U.S. Medicare population. Am J Public Health. 1996;86:70–72.
Sharkness C, Hamburger S, Moore R, Kaczmarek R. Prevalence of artificial hip implants and use of health services by recipients. Public Health Rep. 1993;106:70–74.
Wilson MG, May DS, Kelly JJ. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis. 1994;4:57–67.
Hoagland FT, Oishi CS, Gialamas GG. Extreme variations in racial rates of total hip arthroplasty for primary coxarthrosis: a population-based study in San Francisco. Ann Rheum Dis. 1995;54:107–110.
Katz JN, Chang LC, Sangha O, Fossel AH, Bates DW. Can comorbidity be measured by questionnaire rather than medical record review? Med Care. 1996;34(1):73–84.
Giacomini M. Gender and ethnic differences in hospital based procedure utilization in California. Arch Intern Med. 1996;156:1217–1224.
Escalante A, Espinosa-Morales R, Del Rincon I, Arroyo R, Older S. Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum. 2000;43:390–399.
Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359.
Centers for Disease Control and Prevention (CDC). Racial disparities in total knee replacement among Medicare enrollees-United States, 2000–2006. MMWR Morb Mortal Wkly Rep. 2009;58(6):133–138.
Jones A, Kwoh CK, Kelley ME, Ibrahim SA. Racial disparity in knee arthroplasty utilization in the Veterans Health Administration. Arthritis Rheum. 2005;53(6):979–981.
Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African American and white patients. Arthritis Rheum. 2001;45(4):340–345.
Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patient-level factors. Med Care. 2002;40(1 Suppl):I44–I51.
Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165(10):1117–1124.
Davis MA, Wittinger W, Newhaus J. Obesity and osteoarthritis of the knee: evidence from the national health and nutrition examination survey (NHANES I). Semin Arthritis Rheum. 1990;20:34–41.
Tepper S, Hochberg MC. Factors associated with hip osteoarthritis: data from the first National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol. 1993;137:1081–1088.
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15(12):1833–1840.
Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients' literacy skills. JGIM. 1995;10:537–541.
Baker DW, Williams MV, Parker RM, Gazamararian JA. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33–42.
Cohen S, Mermelstein RJ, Kamarck T, Hoberman HM. Measuring the functional components of social support. In: Sarason IG, Sarason B, eds. Social Support: Theory, Research, and Applications. Holland: The Hague; 1985:73–94.
Kao A, Green D, Zaslavsky A, Koplan J, Cleary P. The relationship between method of physician payment and patient trust. JAMA. 1998;280:1708–1714.
Ware JE Jr, Kosinski M, Keller SD. A 12-Item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–233.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383.
McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum. 2001;45(5):453–461.
Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for total hip and total knee arthroplasties. results of orthopaedic surveys. J Arthroplasty. 1996;11(1):34–46.
Wright JG, Young NL. The patient-specific index: asking patients what they want. J Bone Joint Surg Am. 1997;79(7):974–983.
Hawker GA, Wright JG, Coyte PC, et al. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342(14):1016–1022.
Lorig K, Chastain RL, Ung E, Shoor S, Holman HR. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32(1):37–44.
Hawker GA, Wright JG, Coyte PC, et al. Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences. Med Care. 2001;39(3):206–216.
Hudak PL, Clark JP, Hawker GA, et al. "You're perfect for the procedure! Why don't you want it?" Elderly arthritis patients' unwillingness to consider total joint arthroplasty surgery: a qualitative study. Med Decis Making. 2002;22(3):272–278.
Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56(2):645–646.
Figaro MK, Russo PW, Allegrante JP. Preferences for arthritis care among urban African Americans: "I don't want to be cut". Health Psychol. 2004;23(3):324–329.
Byrne MM, O'Malley KJ, Suarez-Almazor ME. Ethnic differences in health preferences: analysis using willingness-to-pay. J Rheumatol. 2004;31(9):1811–1818.
Byrne MM, Souchek J, Richardson M, Suarez-Almazor M. Racial/ethnic differences in preferences for total knee replacement surgery. J Clin Epidemiol. 2006;59(10):1078–1086.
Figaro MK, Williams-Russo P, Allegrante JP. Expectation and outlook: the impact of patient preference on arthritis care among African Americans. J Ambul Care Manage. 2005;28(1):41–48.
Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Differences in expectation of outcome mediate African-American/White patient differences in "willingness" to consider joint replacement. Arthritis Rheum. 2002;46:2429–2435.
Hawker GA, Wright JG, Badley EM, Coyte PC. Perceptions of, and willingness to consider, total joint arthroplasty in a population-based cohort of individuals with disabling hip and knee arthritis. Arthritis Rheum. 2004;51(4):635–641.
Ang DC, Ibrahim SA, Burant CJ, Siminoff LA, Kwoh CK. Ethnic differences in the perception of prayer and consideration of joint arthroplasty. Med Care. 2002;40:471–476.
Mancuso CA, Graziano S, Briskie LM, et al. Randomized trials to modify patients' preoperative expectations of hip and knee arthroplasties. Clin Orthop Relat Res. 2008;466(2):424–431.
Weng HH, Kaplan RM, Boscardin WJ, et al. Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum. 2007;57(4):568–575.
Acknowledgements
This study was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Service (IIR 04-137, PI: Said A. Ibrahim). Dr. Hausmann’s effort was supported by the Veterans Affairs Health Services Research and Development Career Development Program (RCD 06-287 and ER 0280-1). Dr. Ibrahim is a previous recipient of a VA Health Services Research Career Development Award and the Harold Amos Robert Wood Johnson Scholar Award. Dr. Ibrahim is also supported by a K24 Award (1K24AR055259-01) from the National Institutes of Musculoskeletal and Skin Disorders. The views expressed here are those of the authors and do not represent those of the Department of Veterans Affairs or the United States Government. The authors would like to thank project coordinator Margaret Kerr and members of the research staff: Elizabeth Flatley, Michael Hannon, Laura Johnson, Renee McDade, Matthew McShane, Rebecca Meiksin, Christine Schneider, Rebecca Siders, Lisa Stewart, and Sandra Truax. The authors would also like to thank Kim Hansen and Hilary Peterson for editorial input on this manuscript.
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Hausmann, L.R.M., Mor, M., Hanusa, B.H. et al. The Effect of Patient Race on Total Joint Replacement Recommendations and Utilization in the Orthopedic Setting. J GEN INTERN MED 25, 982–988 (2010). https://doi.org/10.1007/s11606-010-1399-5
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DOI: https://doi.org/10.1007/s11606-010-1399-5