Racial disparity among total knee replacement patients remains constant

Although cause is unknown, communication may lie at the heart of uneven treatment distribution.

Despite a nationwide objective to eliminate racial disparities in total knee replacement by 2010, the total knee replacement rate among blacks remains lower than that of whites. Furthermore, researchers still have no comprehensive understanding why the disparity continues to persist.

A study, featured in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report on Feb. 20, declared the total knee replacement (TKR) rate for blacks to be 39% lower in 2006 than for whites. The rate has not improved since the last recording of data in 2000, when a 37% disparity was noted.

The rates were culled from hospital claims and enrollment record data obtained from the Centers for Medicare & Medicaid Services from 2000 to 2006 for patients 65 years of age and older.

“I think the report was well done,” noted Said A. Ibrahim, MD, MPH. “It confirms something that we suspected. There is a very good documentation of disparity in knee replacement that goes back 10 years or so.”

Said A. Ibrahim

Ibrahim pointed out that the increase in utilization among both races has not meant a decrease in the present disparity.

“The study was timely in the sense that it shows this disparity is widening,” he said. “Even though more African-American patients are getting the procedure, relative to whites, the difference has not closed.”

The report authors note the cause is not apparent, claiming, “The disparities are not explained by varying risk for knee osteoarthritis. Likewise, disparate access to health care probably does not explain the disparities.”

Unsuccessful objectives

The findings come despite the Healthy People 2010 objective dedicated to completely eliminating the racial disparity between total knee replacement patients by the year 2010. In the report, the objective is referred to as “developmental” and lacking “a baseline and target to enable measurement of progress.”

Ibrahim said, “There has not been any direction to close this difference, so we cannot say we tried to do something and it didn’t work. No one has actually proposed anything. One way to think about this is: what interventions have we instituted in the last 10 years that could have closed this gap? The answer is none.”

There are however, few ongoing studies funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the VA Health Services Research and Development Service (HSR&D) that are testing patient-focused interventions to address this disparity, Ibrahim told Orthopedics Today.

An editorial note commenting on the study agrees that there has been little progress made in addressing this issue. “The findings in this report … confirm that little or no progress was made toward achieving this objective from 2000 to 2006,” the editors wrote.

Origins hard to verify

Researchers believe the cause of the disparity could stem from a number of reasons, including a variety of knowledge and beliefs about TKR.

Ibrahim, who has worked extensively in researching the disparity’, agrees that there may be many reasons behind the issue.

“We think that several things that contribute to racial disparity – not just in joint replacement but overall – play a role here,” he said. “There is a patient-side to the issue, which is that some patients may not be informed about the treatment. Some people may not fully understand the risks and benefits of the treatment to make an informed choice.”

Another problem could be a community-wide lack of exposure to the treatment. This is particularly possible in the minority communities. Patients who have received the treatment and have had successful outcomes may not be sharing this information with others in their community, Ibrahim said.

Communication a key

The report lists faulty communication as one of the major factors, stating, “Lower outcome expectations have been associated with unwillingness to undergo TKR; these lower expectations might result from communication gaps with health-care providers or inaccurate information from peers.”

Addressing communication should start with delivery – preparing the message that needs to be conveyed in a way that will prove sufficiently informative for the purposes of both physician and patient.

“Physicians tend to use the same style of communication regardless of who they see,” he said. “Of course, you can look at that from a perspective of where it is actually good – they are not discriminating. On the other hand, it could be a problem,” he added, “because if you are dealing with people who are coming from different backgrounds — both in terms of how they communicate and also in terms of what they know about the treatment — communicating to them in the same way … if it doesn’t contribute to disparity, it may also not do anything about it.”

The effort to close the gap between races should start with a large-scale effort, according to the report.

The most pressing need is for evidence-based quantified information expressed in “hard numbers,” according to Ibrahim.

Being an elective procedure, surgeons may wait for the patient to start the discussion and they are more likely to go in-depth with a patient who demonstrates knowledge of the procedure and a preference in favor of surgery.

However, the lack of comprehensive understanding and knowledge regarding the actual roots of the disparity should not impede the effort to act on what is already known, Ibrahim stated.

“We can’t wait until all the answers about the causes of disparity are there,” he said. “We need to address the gap, while we are trying to figure out other possible long-term solutions such as how to make physicians better communicators … that’s going to be really hard to do, and it requires much more effort, policy and leadership.”

For more information:

• Said A. Ibrahim, MD, MPH, can be reached at VA Pittsburgh Health Care System, 7180 Highland Drive, Pittsburgh, PA 15206; e-mail: said.ibrahim2@va.gov. He has no direct financial interest in any product or company mentioned in this article.

Reference:

• Centers for Disease Control and Prevention. Racial Disparities in Total Knee Replacement Among Medicare Enrollees – United States, 2000-2006. MMWR. 2009;58:133-138.