Effect of a Decision Aid on Access to Total Knee Replacement for Black Patients With Osteoarthritis of the Knee

Abstract

IMPORTANCE Black patients with advanced osteoarthritis (OA) of the knee are significantly less likely than white patients to undergo surgery. No strategies have been proved to improve access to surgery for black patients with end-stage OA of the knee. OBJECTIVE To assess whether a decision aid improves access to total knee replacement (TKR) surgery for black patients with OA of the knee. DESIGN, SETTING, AND PARTICIPANTS In a randomized clinical trial, 336 eligible participants who self-identified as black and 50 years or older with chronic and frequent knee pain, a Western Ontario McMaster Universities Osteoarthritis Index score of at least 39, and radiographic evidence of OA of the knee were recruited from December 1, 2010, to May 31, 2014, at 3 medical centers. Exclusion criteria were history of major joint replacement, terminal illness, inflammatory arthritis, prosthetic leg, cognitive impairment, lack of a telephone, or contraindications to elective replacement surgery. Data were analyzed on a per-protocol and intention-to-treat (ITT) basis. EXPOSURE Access to a decision aid for OA of the knee, a 40-minute video that describes the risks and benefits of TKR surgery. MAIN OUTCOMES AND MEASURES Receipt of TKR surgery within 12 months and/or a recommendation for TKR surgery from an orthopedic surgeon within 6 months after the intervention. RESULTS Among 336 patients (101 men [30.1%]; 235 women [69.9%]; mean [SD] age, 59.1 [7.2] years) randomized to the intervention or control group, 13 of 168 controls (7.7%) and 25 of 168 intervention patients (14.9%) underwent TKR within 12 months (P = .04). These changes represent a 70% increase in the TKR rate, which increased by 86%(11 of 154 [7.1%] vs 23 of 150 [15.3%]; P = .02) in the per-protocol sample. Twenty-six controls (15.5%) and 34 intervention patients (20.2%) in the ITT analysis received a recommendation for surgery within 6 months (P = .25). The difference in the surgery recommendation rate between the controls (24 of 154 [15.6%]) and the intervention group (31 of 150 [20.7%]) in the per-protocol analysis also was not statistically significant (P = .25). Adjustment for study site yielded similar results: for receipt of TKR at 12 months, adjusted ORs were 2.10 (95%CI, 1.04–4.27) for the ITT analysis and 2.39 (95%CI, 1.12–5.10) for the per-protocol analysis; for recommendation of TKR at 6 months, 1.39 (95%CI, 0.79–2.44) and 1.41 (95%CI, 0.78–2.55). CONCLUSIONS AND RELEVANCE A decision aid increased rates of TKR among black patients. However, rates of recommendation for surgery did not differ significantly. A patient-centered counseling and educational intervention may help to address racial variations in the use of TKR for the management of end-stage OA of the knee. TRIAL REGISTRATION clinicaltrials.gov Identifer: NCT01851785

Disparities in Total Knee Replacement: Population Losses in Quality‐Adjusted Life‐Years Due to Differential Offer, Acceptance, and Complication Rates for African Americans

“…Thus far, interventions to reduce TKR disparity have been focused on educational tools and decision aid interventions, and trials involving these tools have met with limited success. 35,36 The mixed results of educational interventions may be due to reticence of Black patients to accept surgery, influenced by a history of unequal treatment in the American medical establishment. 37,38 Given the outsize impact of physician offer, it seems that a focus on the physician's role may help bolster TKR utilization.…”

“…Offer rate is controlled by surgeons; it is a metric over which the professional medical community has some control. Thus far, interventions to reduce TKR disparities have been focused on educational tools and decision aid interventions, and trials involving these tools have met with limited success (35,36). The mixed results of educational interventions may be due to reluctance of African American patients to accept surgery, influenced by a history of unequal treatment in the American medical establishment (37,38).…”

Racial/ethnic variations in knee and hip elective joint replacement in the UK

“…In a study that examined willingness to pay for knee replacement among a sample of patients in Houston, Texas, AA and white participants differed significantly in their willingness to pay for knee replacement even after adjusting for age, income, educational level, and other factors 16 . Fortunately, patient preference is a malleable attitudinal disposition, and there is emerging evidence that using shared decision-making tools such as decision aids may offer opportunities to intervene on this disparity 17 .…”

“…Thirdgeneration disparities research will evaluate interventions targeting observed reasons for the disparity. The frontier of this line of research in the US is actually in fourth-generation research, where the goal is to implement evidence-based patient-centered interventions to improve access to JR surgery for vulnerable populations 17 . Therefore, this team's good work might be just the beginning of more research on this disparity.…”

From me needs knee to knee needs me

“…55,56 However, the review showed that in patients undergoing TKR most studies were on decision aids that were applied outside the encounter between patient and doctor . [57][58][59][60][61] We think that methods and aids that stimulate the interactional process within the clinical encounter between patient and health care provider, such as the one presented in chapter 6, should be subject of implementation and further research. 32,33 Future perspectives for care improvement…”