African-Americans less likely to undergo total joint replacement procedures

Study highlights impact of patient preferences on race disparity in surgeons' recommendations for joint replacement

A recent study by researchers at the VA Center for Health Equity Research and Promotion in Pittsburgh, Pennsylvania, suggests that patient treatment preferences play an important role in racial disparities in total joint replacement utilization observed in the US. Different attitudes toward total joint replacement procedures held by African American and white patients explained racial disparities in whether orthopedic surgeons recommended the procedure to patients. These findings- by Dr. Leslie Hausmann, from the VA, and her colleagues, are published online in the Journal of General Internal Medicine-, published by Springer.

Osteoarthritis of the knee or hip is a leading cause of disability in the US. Total joint replacement is the most effective surgical option available to treat moderate to severe cases. Numerous studies have shown racial disparities in the utilization of the procedure. In particular, African-American patients are significantly less likely than white patients to undergo total joint replacement.

To explore potential reasons for this racial disparity, Dr. Hausmann and her team examined whether orthopaedic surgeons were less likely to recommend total joint replacement to African-American patients compared to white patients, and whether African-American patients were less likely to undergo the procedure within six months of study enrollment.

The researchers recruited patients from orthopedic surgery clinics in two large, tertiary care Veterans Affairs hospitals in Pittsburgh and Cleveland. In total, 120 African-American and 337 white patients seeking treatment for knee or hip osteoarthritis were enrolled. Before their appointment with a surgeon, patients completed a survey asking them about their preferences for total joint replacement as a treatment option and their expectations regarding knee/hip pain management. The actual appointment was audio-taped and the patients were surveyed again after the visit to assess their impression of the exchange. The researchers also examined patients' medical records after the visit and again after six months.

They found that African-American patients were less likely to receive a recommendation for total joint replacement than white patients of similar age and disease severity. This racial difference disappeared when the researchers took patients' willingness to undergo the procedure into consideration, suggesting that race differences in total joint replacement recommendations were largely driven by patient treatment preferences. That is, African Americans showed a lower preference for the procedure than whites, and patients who had a lower preference for the procedure were less likely to receive a recommendation for it. Furthermore, patients who received a recommendation for joint replacement were much more likely to have undergone the procedure within six months compared to those who did not receive a recommendation for joint replacement. Of those patients who received a recommendation for joint replacement, 22% of African Americans had undergone the procedure within six months compared to 45% of whites.

The authors conclude: "These findings underscore the unique importance of patient preference in shaping decision-making about total joint replacement. Given the consistent race differences found in patient preferences for the procedure, coupled with the strong impact of patient preferences on its recommendation in the orthopedic setting, reducing disparities may require efforts to understand patient treatment preferences."