While total knee replacement (TKR) is underutilized by all patients with moderate-to-advanced knee osteoarthritis (OA), African-American and Hispanic patients are less likely to consider this surgery than are their Caucasian counterparts, according to study appearing in the May 23 issue of Archives of Internal Medicine.¹

After controlling for health status and degree of pain and disability, investigators from Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, observed that ethnicity emerged as an independent predictor of preferences, particularly regarding minority patients' expectations about efficacy, familiarity with the procedure, and trust in doctors' recommendations.

"Our findings are encouraging in that they suggest mechanisms to improve utilization of TKR," conclude researchers led by Maria E. Suarez-Almazor, MD, PhD, of the Houston Center for Quality of Care and Utilization Studies at the Michael E. DeBakey Veterans Affairs Medical Center. Specifically, they noted that changes in patients' beliefs can be achieved through better healthcare education communication and by improving physician-patient relationships. "Better education programs targeted at minorities could provide data on outcomes to improve expectation and decision making in these patients," they write.

In the study of 198 patients with OA of the knee, Caucasian patients were more likely than minority patients to have considered undergoing TKR. They were also more likely to consider the surgery a beneficial procedure if their OA worsened and the procedure were recommended by their physician, compared with their African-American and Hispanic counterparts.

African-Americans were least likely to consider surgery despite reporting more serve symptoms and having discussed the procedure with their physician more often than members of the other ethnic groups, the study showed.

 

Physician bias not a mitigating factor

Although it was not a statistically significant difference, African-Americans were more likely to be recommended surgery than their Caucasian counterparts-suggesting that physician bias is not a factor in the discrepancy. In fact, physicians recommended arthroplasty to 27% of African-Americans, compared with 15% of Caucasians and 11% of Hispanics, the study showed.

Patients in the present study were asked about physician recommendations of TKR, as well as whether they had considered having the procedure, their perceptions about the benefits and risks of TKR, their expectations if they were to undergo the procedure, and their trust in physicians and the healthcare system.

"There is a significant underutilization of TKR by patients as a whole because they are afraid of pain and recovery and what they have talked to friends about," says Peter M. Bonutti, MD, of the Bonutti Clinic of St. Anthony's Memorial Hospital in Effingham, Illinois. "In my clinical experience, minority patients are less likely to choose knee surgery and instead tend to use nonsurgical and alternative treatments such as prayer and topical treatments including spraying solvents on knee joints to get pain relief."

 

Patient education will help eliminate misperceptions

More patient education, particularly in minority communities, will go a long way toward correcting the misperceptions about the benefits of TKR, and reaffirm the trust necessary between patient and physician. "There is a disconnect that is amplified in ethnic groups," Dr. Bonutti tells CIAOMed. "Overall, we need to teach patients a little better about efficacy, and hammer these messages home in the ethnic groups that need this surgical treatment."

Of the approximately 2.2 million patients with moderate-to-advanced OA of the knee, only about 400,000 TKRs are performed each year. "Why, in general, do less than 25% of these patients who have justifiable cause to have their knees replaced choose other treatments?" Bonutti asks.

"Clearly education and some promotion in minority communities by physicians could explain the value of TKR and explain how this would help people, as well as establish lines of patient referral," he says. Such a campaign could also showcase success of TKR among members of different ethnic groups.

Dr. Suarez-Almazor and colleagues emphasize that further research is necessary to determine whether shared decision-making between physician and patient in a more culturally sensitive manner will narrow the gap in utilization of TKR between Caucasians and minorities with OA of the knee.

Reference:

Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165:1117-1124.