BACKGROUND/RATIONALE:
This second-generation health disparity study examined the potential role of patient-provider communication and decision-making in the well documented racial disparity in the utilization of elective joint replacement, which is an effective treatment option for end stage ostearthritis, by African-Americans and whites . More specifically, the study assessed whether decision-making at the level of the orthopedic surgeon consult impacts this disparity.

OBJECTIVE(S):
The specific aims of this project were to: (1) assess racial differences in the proportion of patients who receive recommendations for joint replacement as a treatment option, who accept treatment recommendations, who are satisfied with the treatment decision, and who undergo joint replacement surgery within six months of the recommendation; (2) examine racial differences in patient-provider communication content and processes (style/pattern) regarding knee/hip osteoarthritis and joint replacement as a treatment option; and (3) examine the association between doctor-patient communication, patient race, and study outcomes.

METHODS:
This was an observational, cross-sectional study of 544 veterans (142 African-American patients, 394 white and 8 other patients) who were potential candidates for knee or hip joint replacement and who were referred to an orthopedic surgeon for management of knee or hip osteoarthritis at the VA Pittsburgh Healthcare System or the Louis Stokes Cleveland DVA Medical Center.

Data collection for this study occurred in three successive phases. First, study participants completed an initial (baseline) survey prior to the initial orthopedic surgeon visit. This baseline survey assessed patient perceptions, preferences, and expectations regarding chronic knee/hip management and joint replacement as a treatment option. We also surveyed participants about their demographic, socio-economic and psychosocial background. Second, the orthopedic clinic visit was audiotaped. Lastly, after the visit, patients were surveyed about their impression of the clinical encounter. Medical records of enrolled patients were also abstracted for information on comorbidity using the Charlson index and surgical recommendation from the orthopedic surgeons' notes. We also collected information on patient's weight and height to calculate Body Mass Index (BMI) and assessed whether patients were seen in previous orthopedic visits (i.e., frequency) or not. Because of the possibility that some veterans may receive joint replacement in the private sector, we telephoned patients six months after enrollment to determine whether they had undergone joint replacement anywhere. For those who reported undergoing surgery within the VA system, this was confirmed by medical record review.

FINDINGS/RESULTS:
Although the final analysis is ongoing and has yet to be submitted for peer review, our preliminary analyses have revealed the following findings which have been presented in abstract format at the 2009 VA HSR&D annual meeting and are currently under review for the Journal of General Internal Medicine:

1. Rate of Total Joint Replacement (TJR) recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for African Americans (AA) than white patients of similar age and disease severity (OR=0.46, 95% CI=0.26-0.83; P=0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR=0.69, 95% CI=0.36-1.31, P=0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients with similar indications (OR=0.41, 95% CI=0.16-1.05, P=0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR=0.63, 95% CI=0.22-1.79, P=0.39).

2.We found that orthopedic surgeons utilize a similar pattern of communication regardless of the patient's race.

3.Differences in doctor patient communication do not appear to mediate the treatment recommendation. However, there is preliminary evidence that African-American patients communicate less about medical information to their doctor compared to white patients. This difference, which will be explored more in-depth in future analysis may reflect differences in educational level or health literacy.

IMPACT:
This study is one of the first in the nation to examine joint replacement utilization disparity at the level of the orthopedic consultation. The findings are highly informative and will shape the design of interventions to address this disparity. Specifically, this study suggests that a patient-centered, educational intervention to better inform preference would help reduce racial differences in recommendation rates. It is with this in mind that our team of investigators is planning further research which will assess the effectiveness of a patient-centered intervention at the orthopedic consult level to reduce this disparity.

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External Links for this Project

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PUBLICATIONS:

None at this time.

DRA: none
DRE: Treatment - Observational
Keywords: Chronic disease (other & unspecified), Communication -- doctor-patient, Minority
MeSH Terms: none