Total hip and knee replacements are among the most effective and cost-effective interventions introduced in the past 60 years, across all areas of medicine. Unfortunately, the benefits of joint replacement are not shared equally among persons with advanced arthritis. Black individuals are at least as likely as White individuals to experience advanced arthritis but are >30% less likely to undergo total hip or knee replacement than White individuals, after adjusting for age and sex1,2. Similar disparities have been observed in cardiac, vascular, and other surgical procedures3.
These disparities were documented over 30 years ago and stimulated the investigation of factors that underlie racial differences in the use of total joint replacement (TJR). These studies identified a number of potential explanations, including a greater fear of TJR risks and less familiarity with the benefits of TJR among Black patients, lower rates of referral of Black patients to orthopaedic surgeons, and lower rates of offering TJR to Black patients among orthopaedic surgeons4-6. It is reasonable to ask whether the greater awareness of racial disparities in joint replacement use has mitigated the disparity among Blacks and Whites over the past 2 decades.
In this article, Thirukumaran et al. examine this question in a sophisticated, careful analysis of differences in the use of total hip and knee replacement among Black and White beneficiaries in the Medicare population between 2009 and 2017. The investigators stratified these racial groups by Medicaid eligibility, a variable in Medicare claims data that identifies Medicare beneficiaries with family incomes ≤138% of the federal poverty level.
The investigators determined that, over the 9-year study period, age and sex-adjusted total hip replacement rates increased by 33%, and total knee replacement rates were essentially unchanged. The investigators showed that the gap in total hip replacement rates between Black patients and White patients widened over this 9-year period, and the gap in total knee replacement rates between Black patients and White patients was unchanged. By 2017, Black patients were at least 30% less likely to undergo these procedures than White patients.
Thirukumaran et al. demonstrated that this racial disparity in TJR rates was not explained by poverty status. That is, Black patients had lower rates of TJR than White patients both among Medicaid-eligible (poor) and Medicare-ineligible (non-poor). Further, poverty had a powerful influence on joint replacement rates. Poor (Medicaid-eligible) Black patients had much lower rates of total knee replacement and total hip replacement than non-poor Black patients. Similarly, poor (Medicaid-eligible) White patients had much lower rates of total knee replacement and total hip replacement than non-poor White patients. Thus, both Black race and poverty status substantially and independently predicted lower rates of total hip and knee replacement throughout the study period. Sadly, racial and income disparities in joint replacement utilization persist 30 years after these disparities were first noted2.
The authors also noted that hospital service areas with higher proportions of Black beneficiaries or of Medicaid-eligible beneficiaries had lower rates of total hip replacement and total knee replacement than areas with lower proportions of Black beneficiaries or dual-eligible beneficiaries. That is, the concentration of Black or poor individuals in an area influences the disparity in rates, suggesting that both individuals’ race and the racial composition of the neighborhoods in which they live drive differential use.
Because Medicare covers the costs of total hip replacement and total knee replacement, the disparity cannot be attributed to a lack of insurance or to a lack of financial access. Also, although rural poor beneficiaries may live far from centers in which joint replacement is performed, urban poor and Black beneficiaries generally live near major medical centers. Thus, disparities cannot be attributed to the physical access to care. In 2003, Skinner et al. showed that racial disparities in total knee replacement rates varied across hospital service areas, with some areas having similar total knee replacement rates in Black and White patients and others having vastly disparate rates1. Thus, the phenomena giving rise to disparities are more prominent in some areas than in others.
Clearly, interventions to mitigate these disparities are needed. On this front, there is some promising research. Ibrahim et al. showed that Black patients with advanced knee osteoarthritis who were randomized to receive a shared-decision-making tool had higher rates of total knee replacement than Black patients who received a control intervention7. The shared-decision-making tool was a 40-minute video that explained the risks and benefits of surgical procedures and encouraged patients to examine their own preferences with regard to pain relief, functional improvement, and surgical risk and to discuss these preferences with their physicians.
Decision aids generally lower the use of total joint replacement, suggesting that, when given a full explanation of the risks, benefits, and alternatives, some patients who might otherwise have chosen a surgical procedure opt instead for conservative therapy8,9. In this light, the greater utilization of total knee replacement in Black patients who had been assigned the shared-decision-making tool than in Black patients who had typical conversations with their physicians suggests that clinicians are not effectively communicating the availability of total knee replacement to their Black patients. To the extent that shared decision-making should be baked into our practices, in their trial, Ibrahim et al. suggested that physicians can do better.
Preference-based discussions are not a panacea. Structural racism infects heath care at many levels. Generations of barriers to quality care and distrust among Black individuals of health-care providers and institutions will not be erased after a 40-minute video. However, the findings of Ibrahim et al. provided at least 1 pathway to narrowing the gaping disparity in TJR rates. These observations, and the persistence of disparities over 3 decades, should impel clinicians and clinical program leaders to ensure that patients with advanced arthritis are well-informed of their options and are fully empowered to choose TJR if it suits their preferences.
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