Race not a 'substantial' predictor of functional outcomes after total knee replacement
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Race was not a “substantial, independent predictor” of functional outcomes following total knee replacement, but marginal differences in care were observed across treatment settings, according to data published in Arthritis Care & Research.
“Unfortunately, research regarding race disparities in functional outcomes following [total knee arthroplasty] is scant,” Allyn M. Bove, PT, DPT, PhD, of the University of Pittsburgh School of Health and Rehabilitation Sciences, and colleagues wrote. “To maximize functional outcomes, patients undergoing TKA require high-intensity rehabilitation for weeks or months beyond the post-operative hospitalization to regain strength and physical function.”
“This is particularly important for Black patients, because they tend to exhibit poorer function pre-operatively — this may be due to Black patients having lower expectations regarding recovery following TKA and delaying surgery in favor of nonsurgical treatments. However, studies investigating post-operative disparities in TKA have not examined the role of physical therapy (PT) in functional outcomes. Overall, evidence suggests there may be race disparities in functional outcomes after TKA, but this has not been well-studied. There is also a lack of knowledge regarding disparities in postoperative PT utilization.”
To examine whether race predicts functional outcomes following total knee replacement, and to assess race differences in the use of post-acute physical therapy after the procedure, Bove and colleagues conducted an observational cohort study of Black of white patients with end-stage knee osteoarthritis. Participants were recruited from 2015 to 2018 through advertisements in surgery offices, referrals from a research registry, and mailers.
Individuals were included in the study if they had been scheduled for a primary unilateral total knee replacement, were non-Hispanic “white/Caucasian” or “Black/African-American,” and spoke English. Those scheduled for simultaneous bilateral or revision total knee replacements, as well as those who failed to receive the scheduled surgery, were excluded.
In all, the researchers collected data on 104 patients, of whom 75 were white and 29 were Black. All 104 participants completed baseline questionnaires. Collected data included pre- and post-operative physical function information, as well as post-operative rehabilitation information. A total of 96 patients — including 69 white and 27 Black participants — completed the follow-up survey. The researchers performed regression analyses and independent samples t-tests to analyze the predictive value of race on post-surgical functional outcome, as well as to compare physical therapy use in various post-acute settings.
According to the researchers, all participants reported receiving acute care or hospital physical therapy. Total physical therapy was similar between white and Black participants, with a mean between-group difference of 2.6 hours. Although this indicates that Black patients averaged 156 fewer minutes of physical therapy than white participants, it was not statistically significant (P = .36), the researchers wrote.
However, there were some differences in physical therapy use within specific settings.
Approximately 27.6% of Black patients were admitted to skilled nursing facilities, compared with 17.3% of white participants. In the full cohort of both groups, neither length of stay (P = .45) nor hours of physical therapy received (P = .49) were significantly different between Black and white patients in these facilities. In addition, these results were similar in the subsample of 21 patients who were discharged to a skilled nursing facility.
Most participants in both groups reported receiving home health physical therapy, but a
significantly larger proportion of Black patients received home health (2 = 5.58; P = .02). The number of visits received was also significantly higher among Black participants than whites — an average of 6.2 vs. 4.7 (P = .05).
Lastly, most patients in both groups received outpatient physical therapy — 88% among white participants and 82.8% among Black participants. Although the duration of care was shorter for white participants than Black participants — a mean 56.8 days vs. 71.2 days — this difference was not significant (P = .06), the researchers wrote.
In addition, although Black patients averaged longer physical therapy duration of care in the outpatient setting, they on average received one fewer visit and 5 fewer hours. According to the researchers, this indicates that Black participants had less intensive outpatient physical therapy. However, neither between-group difference was statistically significant.
“In this sample, there were differences in where people received physical therapy after knee replacement surgery — Black patients received more home health, while white patients received more outpatient physical therapy,” Bove told Healio Rheumatology. “However, the total amount of post-operative rehabilitation was similar between Black and white patients, and the functional improvement was similar between Black and white patients. Therefore, we may reasonably conclude that equitable provision of post-operative rehabilitation after knee replacement may be key in promoting equitable outcomes for patients.”
“We know that Black patients tend to have lower physical function at the time of knee replacement surgery than white patients, and physical therapists are uniquely positioned to ‘close the gap’ in post-operative function and ensure a positive outcome for all patients,” she added. “Physical therapists should routinely assess physical function and work hard to ensure that rehab services continue until patients achieve their functional goals.”
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