BACKGROUND/RATIONALE:
The proposed project represents the next phase in a trajectory of VA research designed to eliminate racial disparities in the utilization of knee joint replacement - an effective treatment option for end-stage knee osteoarthritis (OA). Numerous studies have documented the existence of marked racial disparities in the utilization of knee joint replacement in OA. African-Americans (AA) are two to five times less likely than white patients to receive knee joint replacement for lower extremity OA. Our prior work has shown that compared to white patients, AA patients expect worse outcomes from this treatment and, consequently, are less willing to consider joint replacement even when clinically indicated and recommended by a physician. Patient willingness, an attitudinal disposition modifiable with education, has emerged as a key patient-level mediator in the utilization of elective medical procedures, such as knee joint replacement.
OBJECTIVE(S):
The short-term goals of this randomized, controlled trial are to demonstrate the efficacy of an intervention to improve understanding of knee joint replacement risks, benefits, and expected outcomes among AA primary care patients, increase willingness to consider knee joint replacement among AA primary care patients, and increase primary care referral rates for surgical consideration for AA patients who meet the indications for knee joint replacement.
Specific Aims: 1) To examine the effectiveness of the proposed intervention strategy (evidence-based knee OA decision aid alone or in combination with motivational interviewing) to improve willingness to consider knee joint replacement when clinically indicated among AA primary care patients; 2) Examine the effectiveness of the proposed intervention strategy on patient expectations of knee joint replacement risks/benefits among AA primary care patients; and 3) To examine the effectiveness of the proposed intervention strategy in increasing primary care referrals for surgical evaluation of AA patients with knee OA.
Secondary Aim: To examine the effectiveness of the proposed intervention strategy to increase AA patient likelihood of receiving knee joint replacement within 12 months of the intervention.
METHODS:
A randomized, controlled factorial design will be utilized to examine the effectiveness of knee OA decision aid and/or MI compared with attention control on select key patient-centered and process of care outcomes. We will recruit approximately 600 AA primary care patients (150 at the VAPHS; 150 at the Louis Stokes Cleveland VAMC, and 300 at the PVAMC) who meet the American College of Rheumatology clinical indications for knee joint replacement and randomize them either intervention arms or attention control. We will assess patient expectations, willingness and referral to joint replacement.
FINDINGS/RESULTS:
Active recruitment began January, 2007 and will continue through next year. At this time no preliminary analysis has been completed.
IMPACT:
There is ample evidence that racial/ethnic minority patients have lower rates of total joint replacement than whites, despite evidence that the prevalence of OA is as high or higher among AAs as compared to whites. Therefore, there is a critical need to examine effective strategies to reduce this disparity and to decrease disability from knee OA while improving quality of life for our nation's veterans. This intervention will improve quality of care for African-American VA patients who have end-stage knee OA, a major cause of disability and functional decline in VA elderly patients.
PUBLICATIONS:
Journal Articles
- 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.
