BACKGROUND/RATIONALE:
There are substantial differences in the rates that black and white veterans with osteoarthritis undergo joint replacement surgery. Expectations of the outcomes of surgery such as functional status, pain, and quality of life are likely to influence the willingness of patients to undergo surgery, yet it is unknown if blacks and white differ in their beliefs about the likely benefits of elective joint replacement.
OBJECTIVE(S):
A cross-sectional study design will be utilized to examine the following Specific Aims: 1) To examine ethnic differences in willingness to consider joint replacement, cultural factors (i.e., religiosity, trust in physicians, and risk attitudes) and clinical context factors (i.e., knowledge about joint replacement, arthritis self-efficacy, and expectations of outcome following joint replacement); 2) To examine cultural and clinical context determinants of willingness to consider joint replacement, including cultural factors such as religiosity, trust in physicians, and risk attitudes, and clinical context factors such as knowledge about joint replacement, arthritis self-efficacy, and expectations of outcome following joint replacement; and 3) To determine whether the cultural and clinical context determinants from Specific Aim #2 mediate the relationship between ethnicity and willingness to consider joint replacement.
METHODS:
We performed a cross-sectional survey of 939 veterans (459 AA, 480 whites) ages 50 to 79 years old with chronic moderate-to-severe knee/hip pain; that is, potential candidates for joint replacement, from veterans receiving primary care in the Pittsburgh VA Health Care System and the Philadelphia VA Medical Center. Standardized, validated questionnaires were used to obtain information on potential determinants of willingness to consider joint replacement.
Patients were eligible to enroll in the study if they indicated moderate or severe joint pain and disability, as indicated by their Western Ontario and McMaster Universities Osteoarthritis Index. We used Mancuso's previously-validated Hospital for Special Surgery Joint Replacement Expectations Survey (HSS-JRES) to assess patients’ expectations for pain relief, functional improvement, and psychological well-being after joint replacement surgery.
FINDINGS/RESULTS:
Although AA’s had lower expectations for knee and hip replacement surgery, this difference was in part due to differences in income and educational level. Patient expectations for surgical outcomes were strong predictors of preference for joint replacement. In veterans with hip/knee OA, AA’s were more likely than whites to consider prayer as an important coping strategy for chronic pain. Risk preferences varied among the participants, but risk preferences did not vary by race, educational level, income or age. Although AA’s had lower health literacy compared to whites, health literacy was not related to willingness to consider joint replacement. Referral to specialist care; that is, to a rheumatologist or an orthopedic surgeon, was not related to race but was related to patient preference for joint replacement and receipt of disability payments due to hip/knee pain.
IMPACT:
Among veterans with moderate-to-severe osteoarthritis, whites have substantially higher expectations for the physical, functional, and psychological benefits of joint replacement surgery. Expectations of joint replacement outcomes are related to patient preferences for surgery.
Implications for Policy, Delivery or Practice: Culturally competent pre-operative educational programs for joint replacement surgery may be needed.
PUBLICATIONS:
Journal Articles
- Groeneveld PW, Kwoh CK, Mor MK, Appelt CJ, Geng M, Gutierrez JC, Wessel DS, Ibrahim SA. Racial differences in expectations of joint replacement surgery outcomes. Arthritis and Rheumatism. 2008; 59(5): 730-7.
- Emejuaiwe N, Jones AC, Ibrahim SA, Kwoh CK. Disparities in joint replacement utilization: a quality of care issue. Clinical and Experimental Rheumatology. 2007; 25(6 Suppl 47): 44-9.
