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IIR 05-234 – HSR&D Study

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IIR 05-234
Knee Replacement Disparity: A Randomized, Controlled Intervention
C. Kent Kwoh MD
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: September 2006 - August 2010

BACKGROUND/RATIONALE:
This project represents the next phase in a trajectory of VA research designed to eliminate racial disparities in the utilization of knee joint replacement - an effective treatment option for end-stage knee osteoarthritis (OA). Numerous studies have documented the existence of marked racial disparities in the utilization of knee joint replacement in OA. African-Americans (AA) are two to five times less likely than white patients to receive knee joint replacement for lower extremity OA. Our prior work has shown that compared to white patients, AA patients expect worse outcomes from this treatment and, consequently, are less willing to consider joint replacement even when clinically indicated and recommended by a physician. Patient willingness, an attitudinal disposition modifiable with education, has emerged as a key patient-level mediator in the utilization of elective medical procedures, such as knee joint replacement.

OBJECTIVE(S):
The short-term goals of this randomized, controlled trial were to demonstrate the efficacy of an intervention to improve understanding of knee joint replacement risks, benefits, and expected outcomes among African American (AA) primary care patients, increase willingness to consider knee joint replacement among AA primary care patients, and increase primary care referral rates for surgical consideration for AA patients who meet the indications for knee joint replacement.

Specific Aims: 1) To examine the effectiveness of the proposed intervention strategy (evidence-based knee OA decision aid alone or in combination with motivational interviewing) to improve willingness to consider knee joint replacement when clinically indicated among AA primary care patients; 2) Examine the effectiveness of the proposed intervention strategy on patient expectations of knee joint replacement risks/benefits among AA primary care patients; and 3) To examine the effectiveness of the proposed intervention strategy in increasing primary care referrals for surgical evaluation of AA patients with knee OA. The primary hypothesis is that our educational intervention will lead to higher referral rate to specialty care for patient who received the intervention compared to those who did not.

Secondary Aim: To examine the effectiveness of the proposed intervention strategy to increase AA patient likelihood of receiving knee joint replacement within 12 months of the intervention. A cross-sectional study design will be utilized to examine the following Specific Secondary 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 Secondary Aim #2 mediate the relationship between ethnicity and willingness to consider joint replacement.

METHODS:
A randomized, controlled factorial design examining the effectiveness of knee OA decision aid and/or MI was compared, with attention control on select key patient-centered and process of care outcomes. Approximately 600 AA primary care patients (150 at the VAPHS; 150 at the Louis Stokes Cleveland VAMC, and 300 at the PVAMC) were recruited who meet the American College of Rheumatology clinical indications for knee joint replacement. They were randomized into either intervention arms or attention control. The randomization process involved 2x2 factorial designs where equal numbers of patients were randomized to the following four study arms: 1) Decision aid only 2) MI only 3) MI and decisions aim and 4) control arm. For all randomized patients, the following key outcomes were assessed; patients' expectations, willingness and referral to joint replacement were assessed.

FINDINGS/RESULTS:
Summary of key study results: In both adjusted and unadjusted analysis, in this sample of AA veteran patients with knee osteoarthritis and pain we found that an educational intervention consisting of either DA or MI or a combination did not significantly impact patient preference (as assessed by willingness to consider joint replacement); patient expectations regarding surgical outcomes; or patient likelihood of receiving an appointment or referral with orthopedic specialist. The intervention also did not significantly impact patient's likelihood of engaging the primary care doctor in a discussion about knee pain nor did it increase the odds of undergoing joint replacement within 12 months of the intervention. Future studies are needed to assess other types of interventions to address the marked racial disparity in access and utilization of joint replacement in the management of end-stage knee OA.

IMPACT:
There is ample evidence that racial/ethnic minority patients have lower rates of total joint replacement than whites, despite evidence that the prevalence of OA is as high or higher among AAs as compared to whites. Therefore, there is a critical need to examine effective strategies to reduce this disparity and to introduce system-wide implementations to effectively abate and decrease disability from knee OA while improving the quality of life for our nation's Veterans. This intervention adds to our knowledge about strategies to improve the quality of care for African-American VA patients who have end-stage knee OA, known to be a major cause of disability and functional decline in VA elderly patients.

Dr. Ibrahim and colleagues carefully designed and methodically executed research program serves as a model for advancing health equity research to detect disparities in joint replacement to understand the reasons for these disparities. Dr. Ibrahim continues his research to effectively reduce the racial disparity in joint replacement utilization across the VA through his work at the Philadelphia VAMC.




PUBLICATIONS:

Journal Articles

  1. Ibrahim SA. Racial variations in the utilization of knee and hip joint replacement: an introduction and review of the most recent literature. Current orthopaedic practice. 2010 Mar 1; 21(2):126-131.
  2. 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.
Journal Other

  1. Ibrahim SA. Decision Aids and Elective Joint Replacement - How Knowledge Affects Utilization. [Editorial]. The New England journal of medicine. 2017 Jun 29; 376(26):2509-2511.
Conference Presentations

  1. 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.
  2. Ibrahim SA, Hanusa BH, Hannon M, Kresevic D, Long JA, Kwoh CK. A randomized, controlled educational intervention to reduce racial variation in elective knee replacement. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.
  3. Ibrahim SA, Hanusa BH, Hannon M, Kresevic D, Long JA, Kwoh CK. A randomized, controlled educational intervention to reduce racial variation in elective knee replacement. Poster session presented at: Osteoarthritis Research Society International World Congress; 2012 Apr 27; Barcelona, Spain.
  4. Ibrahim SA. Factors influencing ethnic/racial utilization disparity. Paper presented at: American Academy of Orthopaedic Surgeons Annual Meeting; 2010 May 6; Alexandria, VA.
  5. 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.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Communication -- doctor-patient, Decision support, Patient-centered Care
MeSH Terms: none

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