A Review of the Literature: Comparison of Joint Replacement Disparities in VA and Non-VA Settings

The leading cause of disability in the U.S. is osteoarthritis, and there is no known cure. Consequently, osteoarthritis is managed with a variety of treatments to reduce disability, improve function, and alleviate symptoms. The most effective surgical option for moderate to severe osteoarthritis in the knee or hip is total joint replacement (TJR), which is often considered appropriate in cases where non-surgical treatments have not brought adequate relief. TJR is considered the fastest-growing elective surgery in the nation, if not the world.

Although TJR is highly successful at treating advanced hip or knee osteoarthritis, there is a large body of evidence that disparities exist in the use of TJR in non-VA settings. Investigators at the VA Evidence-based Synthesis Program at the West Los Angeles VAMC conducted a review of the literature from 1966 through 2011 to compare what is known about disparities in TJR in VA healthcare settings to disparities outside the VA.

After screening more than 285 articles, 69 articles were chosen in order to answer these three key questions:

Question #1
What is the evidence about the existence and magnitude of disparities in joint replacement surgery in VA? How does this compare to published studies from non-VA U.S. populations?

• It is a consistent finding in non-VA studies of U.S. populations that African American patients receive fewer total knee replacements (TKRs) than whites, and men receive fewer TKRs than women.
• Data supporting the existence of disparities in joint replacement surgery in VA is limited to three studies, two of which focus on racial disparities and only one of which focuses on gender disparities. Two of these studies contain data more than 10 years old, and the third contains data from a small sample in only two VA facilities. While the magnitude of the racial disparities is about the same as shown in non-VA populations (1.5- to 3-fold), based on the sparseness and age of the data, further research may show different findings.
• There is scant data about differences in utilization and disparities for total hip replacement in both non-VA and VA populations, thus no conclusions could be drawn.
• There is scant data about differences in utilization of joint replacement for other races (Hispanic, Asian), thus no conclusions could be drawn.

Question #2
What is the evidence about patient-level, provider-level, and system-level factors that contribute to disparities in joint replacement surgery in VA? How does this compare to published studies from non-VA populations?

• Evidence about the patient-, provider-, and system-level factors that contribute to disparities in joint replacement surgery in the VA comes from a series of small studies recruiting patients from one or two VAMCs. However, these studies suggest that African American Veterans, compared to whites, have lower expectations about the effectiveness of joint replacement, less familiarity with joint replacement, and may be more likely to view prayer and other techniques as useful for the management of arthritis pain. In addition, there is some evidence that African Americans may be less likely to be referred to specialists for joint replacement or recommended TJR by a specialist, although some of these differences may be explained by patient preference. One study examining communication between patients and orthopedic surgeons in the VA found little difference by race.
• There is little data about reasons for disparities for other races (Hispanic, Asian), thus no conclusions could be drawn.
• Evidence in non-VA settings suggests that minority patients (mainly African Americans) may have less knowledge about joint replacement surgery, less perceived health benefits, and greater fear of joint replacement surgery - similar to findings within VA. Minority patients also may be less likely to be treated in high-volume centers or by high-volume providers, which is a system-level factor that has not yet been studied within VA.

Question #3
What is the evidence regarding VA or non-VA interventions to reduce disparities in joint replacement surgery?

• There has been only one published VA study of an intervention to improve disparities, and it focused on changing patients' expectations and only examined TKR.

Suggestions for Future Research
The reviewed VA studies were well-designed, but a better and more current understanding of the reasons for the observed disparities is needed in order to design studies of interventions that are most likely to succeed. Additionally, with the increasing number of women Veterans, researchers should plan now to learn more about the use of TJR among women Veterans.

Future studies could assess the current utilization of TJR in a national or representative sample of Veterans and VISNs to establish the magnitude of any differences in utilization in TJR between male and female Veterans and those of different races. If current data confirm different utilization rates, an in-depth examination should examine the extent to which differences reflect different need for surgery based on severity of symptoms and other clinical factors. Third, if disparities appear to exist even after controlling for appropriate need for surgery, mixed-method types of research will be necessary to help establish the causes and barriers that are contributing to these disparities. This research should examine patient- and provider-level factors and also system-level factors, which may be particularly amenable to the types of quality improvement initiatives that an integrated healthcare system, such as the VA, can implement well. Lastly, based on the results of all the above, VA should test interventions to diminish disparities.

*Cyber Seminar*
A Cyber Seminar session on this ESP Report is scheduled for October 20th, 2011 from 12:00pm-1:15pm ET.

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This report is a product of the HSR&D Evidence-based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference
Gellad WF, Maggard MA, Miake-Lye IM, Shekelle PG. A Comparison of Joint Replacement Disparities in VA and Non-VA Settings: A Systematic Review. VA-ESP Project #05-226; 2011

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This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See the full reports online.