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IIR 04-137 – HSR&D Study

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IIR 04-137
Joint Replacement Utilization Disparity: The Role of Communication
Said A. Ibrahim MD MPH MBA
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: September 2005 - February 2009

BACKGROUND/RATIONALE:
This second-generation health disparity study examined the potential role of patient-provider communication and decision-making in the well documented racial disparity in the utilization of elective joint replacement, which is an effective treatment option for end stage ostearthritis, by African-Americans and whites . More specifically, the study assessed whether decision-making at the level of the orthopedic surgeon consult impacts this disparity.

OBJECTIVE(S):
The specific aims of this project were to: (1) assess racial differences in the proportion of patients who receive recommendations for joint replacement as a treatment option, who accept treatment recommendations, who are satisfied with the treatment decision, and who undergo joint replacement surgery within six months of the recommendation; (2) examine racial differences in patient-provider communication content and processes (style/pattern) regarding knee/hip osteoarthritis and joint replacement as a treatment option; and (3) examine the association between doctor-patient communication, patient race, and study outcomes.

METHODS:
This was an observational, cross-sectional study of 544 veterans (142 African-American patients, 394 white and 8 other patients) who were potential candidates for knee or hip joint replacement and who were referred to an orthopedic surgeon for management of knee or hip osteoarthritis at the VA Pittsburgh Healthcare System or the Louis Stokes Cleveland DVA Medical Center.

Data collection for this study occurred in three successive phases. First, study participants completed an initial (baseline) survey prior to the initial orthopedic surgeon visit. This baseline survey assessed patient perceptions, preferences, and expectations regarding chronic knee/hip management and joint replacement as a treatment option. We also surveyed participants about their demographic, socio-economic and psychosocial background. Second, the orthopedic clinic visit was audiotaped. Lastly, after the visit, patients were surveyed about their impression of the clinical encounter. Medical records of enrolled patients were also abstracted for information on comorbidity using the Charlson index and surgical recommendation from the orthopedic surgeons' notes. We also collected information on patient's weight and height to calculate Body Mass Index (BMI) and assessed whether patients were seen in previous orthopedic visits (i.e., frequency) or not. Because of the possibility that some veterans may receive joint replacement in the private sector, we telephoned patients six months after enrollment to determine whether they had undergone joint replacement anywhere. For those who reported undergoing surgery within the VA system, this was confirmed by medical record review.

FINDINGS/RESULTS:
Although the final analysis is ongoing and has yet to be submitted for peer review, our preliminary analyses have revealed the following findings which have been presented in abstract format at the 2009 VA HSR&D annual meeting and are currently under review for the Journal of General Internal Medicine:

1. Rate of Total Joint Replacement (TJR) recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for African Americans (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 with similar indications (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=0.63, 95% CI=0.22-1.79, P=0.39).

2.We found that orthopedic surgeons utilize a similar pattern of communication regardless of the patient's race.

3.Differences in doctor patient communication do not appear to mediate the treatment recommendation. However, there is preliminary evidence that African-American patients communicate less about medical information to their doctor compared to white patients. This difference, which will be explored more in-depth in future analysis may reflect differences in educational level or health literacy.

IMPACT:
This study is one of the first in the nation to examine joint replacement utilization disparity at the level of the orthopedic consultation. The findings are highly informative and will shape the design of interventions to address this disparity. Specifically, this study suggests that a patient-centered, educational intervention to better inform preference would help reduce racial differences in recommendation rates. It is with this in mind that our team of investigators is planning further research which will assess the effectiveness of a patient-centered intervention at the orthopedic consult level to reduce this disparity.

PUBLICATIONS:

Journal Articles

  1. Hausmann LR, Kwoh CK, Hannon MJ, Ibrahim SA. Perceived racial discrimination in health care and race differences in physician trust. Race and social problems. 2013 Jun 1; 5(2):113-120.
  2. Hausmann LR, Hannon MJ, Kresevic DM, Hanusa BH, Kwoh CK, Ibrahim SA. Impact of perceived discrimination in healthcare on patient-provider communication. Medical care. 2011 Jul 1; 49(7):626-33.
  3. Hausmann LR, Hanusa BH, Kresevic DM, Zickmund S, Ling BS, Gordon HS, Kwoh CK, Mor MK, Hannon MJ, Cohen PZ, Grant R, Ibrahim SA. Orthopedic communication about osteoarthritis treatment: Does patient race matter? Arthritis care & research. 2011 May 1; 63(5):635-42.
  4. Hausmann LR, Mor M, Hanusa BH, Zickmund S, Cohen PZ, Grant R, Kresevic DM, Gordon HS, Ling BS, Kwoh CK, Ibrahim SA. The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting. Journal of general internal medicine. 2010 Sep 1; 25(9):982-8.
  5. 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. Hausmann LR, Brandt C, Carroll C, Fenton B, Ibrahim S, Becker W, Burgess D, Wandner L, Bair M, Goulet J. Race/Ethnicity and Total Knee Arthroplasty Rates in the VA Healthcare System: A Prospective Analysis of a Large Cohort. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  2. Hausmann LR, Brandt C, Carroll C, Fenton BT, Ibrahim SA, Becker W, Burgess D, Wandner L, Bair MJ, Goulet JL. Racial and Ethnic Differences in Total Knee Arthroplasty in the Veterans Affairs Healthcare System from 2001 - 2014. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  3. Trivedi AN, Nsa W, Hausmann LR, Lee J, Ma A, Bratzler D, Baus K, Larbi F, Fine MJ. Trends in the quality of care and racial/ethnic disparities in US hospitals, 2005-2010. Paper presented at: Society of General Internal Medicine Annual Meeting; 2013 Apr 23; Denver, CO.
  4. Hausmann LR, Kwoh CK, Hannon M, Ibrahim SA. Patient race, perceptions of racism in healthcare settings, and physician trust. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ.
  5. Ibrahim SA. Factors influencing ethnic/racial utilization disparity. Paper presented at: American Academy of Orthopaedic Surgeons Annual Meeting; 2010 May 6; Alexandria, VA.
  6. Hausmann LR, Hannon M, Kresevic D, Hanusa BH, Kwoh CK, Ibrahim SA. Perceived discrimination in health care and its association with patient-provider communication. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2010 Feb 25; San Francisco, CA.
  7. Ibrahim SA. VA-funded disparities research: the case of joint replacement utilization. Paper presented at: Winston-Salem State University National Conference to End Health Disparities II; 2009 Nov 6; Winston-Salem, NC.
  8. Ling BS, Hausmann LR, Mor MK, Geng M, Ibrahim SA. Patient-provider communication and informed decision making for patients with knee or hip osteoarthritis in the orthopedic setting within the VA. Presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami Beach, FL.
  9. Hausmann LR, Hanusa BH, Geng M, Ibrahim SA. The impact of African American patients’ perceptions of past racial discrimination in healthcare on subsequent patient-provider communication. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2009 Apr 22; Montréal, Canada.
  10. Borrero SB, Nikolajski C, Zickmund S, Kresevic D, Mor M, Geng M, Ibrahim SA. Race and doctor-patient communication about treatment preference. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  11. Hausmann L, Hanusa B, Kresevic D, Mor M, Gordon HS, Geng M, Ibrahim S. Race and joint replacement recommendation: the role of preference and doctor-patient communication. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  12. Ling B, Hausmann L, Mor M, Geng M, Ibrahim S. Informed decision-making in the orthopedic setting within the VA. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  13. Hausmann LRM, Kresevic D, Cohen PZ, Grant R, Kwoh CK, Mor M, Geng M, Ling BS, Ibrahim SA. Doctor-patient communication and the racial disparity in recommendations for joint replacement. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.
  14. Hausmann LRM, Kresevic D, Cohen PZ, Grant R, Zickmund SL, Mor M, Geng M, Gordon HS, Ibrahim SA. Patient race and doctor-patient communication in the orthopedic setting. Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.
  15. Hausmann LRM, Mor MK, Geng M, Zickmund SL, Ling BS, Kresevic D, Gordon HS, Cohen PZ, Grant R, Ibrahim SA. Race and patient-provider concordance on treatment recommendation for joint replacement. Paper presented at: Leo H. Criep on Patient-Provider Communication Annual Symposium; 2007 Nov 15; Pittsburgh, PA.
  16. Hausmann LRM, Mor M, Geng M, Kresevic D, Cohen PZ, Grant R, Ibrahim A. Perceptions of past racial discrimination in healthcare diminish African American patients' satisfaction with subsequent treatment recommendations. Poster session presented at: Society for Medical Decision Making Annual Meeting; 2007 Oct 21; Pittsburgh, PA.
  17. Hausmann LRM, Mor M, Geng M, Zickmund SL, Ling BS, Kresevic D, Gordon HS, Cohen PZ, Grant R, Ibrahim SA. Race and patient-provider concordance on treatment recommendation for joint replacement. Paper presented at: Society for Medical Decision Making Annual Meeting; 2007 Oct 21; Pittsburgh, PA.
  18. 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.
  19. 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.
  20. 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.


DRA: none
DRE: Treatment - Observational
Keywords: Chronic disease (other & unspecified), Communication -- doctor-patient, Minority
MeSH Terms: none

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