Patient Perceptions Around Surgery, Pain Contribute to Racial Disparity in Total Knee Replacement

A study in Arthritis Research & Therapy suggests that patient preferences make up the lion’s share of the disparity in white and African-American patients who undergo total knee replacement (TKR).

The findings are important, because they put into context the marked racial disparities in the utilization of TKR for relief of osteoarthritis (OA) after more conservative therapies are no longer able to provide adequate pain relief. Using Medicare claims data, the study authors estimated that the annual rate of TKR was 4.84 per 1,000 among African-American (AA) women, compared to 5.97 per 1,000 among white women. The rate for AA men (1.84 per 1,000) was dramatically lower than that for white men (4.82 per 1,000).

“Reasons for racial disparities in TKR utilization rate are complex and involve patient-level, provider-level, and system-level factors,” the researchers noted. “Patient preference has emerged as a key factor, however. It is a strong predictor of time to receipt of a first total joint replacement. Patient preference in joint replacement may also vary by race, sex, and other sociodemographic factors. In studies of veterans with advanced knee or hip OA, AAs were consistently less willing to consider joint replacement compared to whites.”

Participants were recruited from the University of Pittsburgh and the Veterans Affairs (VA) Pittsburgh Healthcare System clinics and through mailings and advertisements. Five hundred fourteen white and 285 AA patients with chronic knee pain and radiographic evidence of OA participated in the study.

Compared to whites, AAs were less willing to undergo TKR (80% vs. 62%, respectively). The study takes an interesting look at the psychology of choosing surgery over homeopathic and other potential remedies. In the case of joint replacement, for example, whites are more likely to believe that TKR is efficacious and are more likely to be familiar with the procedure than AAs, who are more likely to expect surgical complications. Communication with health care providers may also be a lingering complication.

Among AAs, better understanding of the procedure, perceiving a short hospital course, and believing in less post-surgical pain and walking difficulties also determined willingness. Among whites, surgical discussions with a physician and higher trust in the healthcare system determined willingness to undergo TKR.

“Decision aids and other educational tools may be designed to educate patients about the benefits and risks of the procedure, and expectations for during and after the procedure,” the study authors concluded. “Educational strategies and training targeted towards healthcare professionals may also be developed to improve patient trust in physicians and the healthcare system. As a consequence, we may improve OA patients’ preference towards more effective and evidence-based treatments, including TKR. Eventually, we may be able to personalize intervention programs and reduce racial disparities in the utilization of TKR among OA patients.”