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ECV 03-201 – HSR&D Study

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ECV 03-201
Reasons for Disparities in Joint Replacement Utilization
C. Kent Kwoh MD
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: January 2004 - December 2006

BACKGROUND/RATIONALE:
There are substantial differences in the rates that black and white veterans with osteoarthritis undergo joint replacement surgery. Expectations of the outcomes of surgery such as functional status, pain, and quality of life are likely to influence the willingness of patients to undergo surgery, yet it is unknown if blacks and white differ in their beliefs about the likely benefits of elective joint replacement.

OBJECTIVE(S):
A cross-sectional study design will be utilized to examine the following Specific Aims: 1) To examine ethnic differences in willingness to consider joint replacement, cultural factors (i.e., religiosity, trust in physicians, and risk attitudes) and clinical context factors (i.e., knowledge about joint replacement, arthritis self-efficacy, and expectations of outcome following joint replacement); 2) To examine cultural and clinical context determinants of willingness to consider joint replacement, including cultural factors such as religiosity, trust in physicians, and risk attitudes, and clinical context factors such as knowledge about joint replacement, arthritis self-efficacy, and expectations of outcome following joint replacement; and 3) To determine whether the cultural and clinical context determinants from Specific Aim #2 mediate the relationship between ethnicity and willingness to consider joint replacement.

METHODS:
We performed a cross-sectional survey of 939 veterans (459 AA, 480 whites) ages 50 to 79 years old with chronic moderate-to-severe knee/hip pain; that is, potential candidates for joint replacement, from veterans receiving primary care in the Pittsburgh VA Health Care System and the Philadelphia VA Medical Center. Standardized, validated questionnaires were used to obtain information on potential determinants of willingness to consider joint replacement.

Patients were eligible to enroll in the study if they indicated moderate or severe joint pain and disability, as indicated by their Western Ontario and McMaster Universities Osteoarthritis Index. We used Mancuso's previously-validated Hospital for Special Surgery Joint Replacement Expectations Survey (HSS-JRES) to assess patients’ expectations for pain relief, functional improvement, and psychological well-being after joint replacement surgery.

FINDINGS/RESULTS:
Although AA’s had lower expectations for knee and hip replacement surgery, this difference was in part due to differences in income and educational level. Patient expectations for surgical outcomes were strong predictors of preference for joint replacement. In veterans with hip/knee OA, AA’s were more likely than whites to consider prayer as an important coping strategy for chronic pain. Risk preferences varied among the participants, but risk preferences did not vary by race, educational level, income or age. Although AA’s had lower health literacy compared to whites, health literacy was not related to willingness to consider joint replacement. Referral to specialist care; that is, to a rheumatologist or an orthopedic surgeon, was not related to race but was related to patient preference for joint replacement and receipt of disability payments due to hip/knee pain.


IMPACT:
Among veterans with moderate-to-severe osteoarthritis, whites have substantially higher expectations for the physical, functional, and psychological benefits of joint replacement surgery. Expectations of joint replacement outcomes are related to patient preferences for surgery.

Implications for Policy, Delivery or Practice: Culturally competent pre-operative educational programs for joint replacement surgery may be needed.

PUBLICATIONS:

Journal Articles

  1. Jones AC, Kwoh CK, Groeneveld PW, Mor M, Geng M, Ibrahim SA. Investigating racial differences in coping with chronic osteoarthritis pain. Journal of Cross-Cultural Gerontology. 2008 Dec 1; 23(4):339-47.
  2. Groeneveld PW, Kwoh CK, Mor MK, Appelt CJ, Geng M, Gutierrez JC, Wessel DS, Ibrahim SA. Racial differences in expectations of joint replacement surgery outcomes. Arthritis Rheum. 2008 May 15; 59(5):730-7.
  3. Emejuaiwe N, Jones AC, Ibrahim SA, Kwoh CK. Disparities in joint replacement utilization: a quality of care issue. Clinical and Experimental Rheumatology. 2007 Nov 1; 25(6 Suppl 47):44-9.
Conference Presentations

  1. Groeneveld PW, Kwoh CK, Mor MK, Geng M, Appelt CJ, Gutierrez JC, Ibrahim SA. Racial differences in joint replacement expectations among veterans with osteoarthritis. Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 27; Toronto, Canada.
  2. Groeneveld PW, Kwoh CK, Mor MK, Geng M, Appelt CJ, Gutierrez J, Ibrahim SA. Racial differences in joint replacement expectations among veterans with osteoarthritis. Paper presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA.
  3. Jones AC, Kwoh CK, Groeneveld PW, Mor MK, Geng M, Ibrahim SA. Prayer is more important to blacks than whites in coping with chronic osteoarthritis pain. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  4. Ibrahim SA, Groeneveld PW, Geng M, Mor MK, Kwoh CK. Preference and disability, but not race, are associated with the likelihood of referral to rheumatology/orthopedic surgery. Poster session presented at: Osteoarthritis Research Society International World Congress; 2006 Dec 6; Prague, Czech Republic.
  5. Stockman C, Groeneveld PW, Kwoh CK, Ibrahim SA. Similarities and divergences in health risk preferences between two cohorts. Poster session presented at: Society for Judgment and Decision Making Annual Meeting; 2006 Oct 18; Houston, TX.
  6. Stockman C, Groeneveld PW, Kwoh CK, Ibrahim SA. Race and risk preferences among veterans with knee/hip osteoarthritis. Paper presented at: Society of General Internal Medicine New England Regional Annual Meeting; 2006 Oct 15; Boston, MA.
  7. Appelt CJ, Hausmann LR, Kwoh CK, Ibrahim SA. Knee replacement decision making among older African- American patients with osteoarthritis. Poster session presented at: Leo H. Criep on Patient-Provider Communication Annual Symposium; 2006 Apr 1; Pittsburgh, PA.
  8. Groeneveld PW, Kwoh CK, Appelt C, Gutierrez J, Resnick A, Ibrahim S. Racial differences in expectations of joint replacement outcomes among veterans with osteoarthritis. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.
  9. Borrero S, Kwoh CK, Sartorius J, Ibrahim SA. Gender and total knee/hip arthroplasty utilization rate in the VA system. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2005 May 1; New Orleans, LA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Ethnic/cultural, Functional status, Utilization patterns
MeSH Terms: none

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