Study Suggests Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement

FINDINGS:

• Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon.
• African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was no longer significant after controlling for Veterans' willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
• African-American and white Veterans differed on many socio-demographic and clinical characteristics. For example, compared to white Veterans, African-American Veterans reported lower incomes and less social support and they were less likely than whites to have adequate health literacy. They also reported more severe arthritis symptoms, less trust in their orthopedic surgeons and lower preference for joint replacement surgery.

BACKGROUND:
Osteoarthritis of the knee or hip is a leading cause of disability in the United States. Although non-surgical treatment options exist (e.g., physical therapy, medications), total joint replacement (TJR) is the most effective surgical option available for treating moderate to severe knee or hip osteoarthritis. Despite the effectiveness of TJR, numerous studies have documented racial disparities in the use of the procedure, both in the private sector and VA. This prospective, observational study examined whether orthopedic surgeons are less likely to recommend TJR to African-American Veterans (n=120) compared to white Veterans (n=337) seeking treatment in two VA orthopedic clinics. Patients were aged 50 and older and were referred to the clinics for management of chronic knee/hip pain between 12/05 and 7/08. Patients were surveyed immediately before and after their orthopedic visit, to assess socio-demographic and clinical variables that could influence treatment decisions (e.g., comorbidities, health literacy, willingness to undergo joint replacement) and to assess their interaction with their doctor. Patient medical records were reviewed to ascertain whether Veterans received a recommendation for TJR from their orthopedic surgeon, and if they then received TJR at the VA within six months of study enrollment.

LIMITATIONS:

• This study does not address potential disparities in other racial or ethnic groups.
• Recommendations and treatments that were documented in patient medical records may have resulted in the misclassification of some patients due to imperfect documentation.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 04-137). Dr. Hausmann also was supported by an HSR&D Career Development Award. Drs. Hausmann, Mor, and Hanusa are part of HSR&D's Center for Health Equity Research and Promotion in Pittsburgh, PA.