Inner city African-American elderly patients' perceptions and preferences for the care of chronic knee and hip pain: findings from focus groups

Are There Racial and Ethnic Variations in Patient Attitudes Toward Hip and Knee Arthroplasty for Osteoarthritis? A Systematic Review

BACKGROUND

It is not clear why people who identify as Black or Hispanic are less likely to undergo discretionary musculoskeletal surgery such as arthroplasty for osteoarthritis of the hip or knee. Inequities and mistrust are important factors to consider. The role of socioeconomic factors and variation in values, attitudes, and beliefs regarding discretionary procedures are less well understood. A systematic review of the evidence regarding mindsets toward knee and hip arthroplasty among Black and Hispanic people could inform attempts to limit disparities in care.

QUESTIONS/PURPOSES

In a systematic review of qualitative and quantitative evidence, we asked: (1) What factors are associated with racial and ethnic variations in attitudes toward discretionary hip and knee arthroplasty for osteoarthritis? (2) Do studies that investigate racial and ethnic variations in mindsets toward discretionary orthopaedic care control for potential confounding by socioeconomic factors?

METHODS

A systematic search of PubMed, Cochrane, and Embase (last searched August 2023) for studies that addressed racial and ethnic variations in mindsets toward discretionary musculoskeletal care use was conducted. We excluded studies that were not published in English, lacked full-text availability, and those that documented patient approaches without comparing them to the willingness to undergo a discretionary procedure. Twenty-one studies were included-14 quantitative and seven qualitative-including 8472 patients. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. The studies included demonstrated low risk of bias: five quantitative studies lacked detail regarding nonresponse bias and one qualitative study lacked details regarding the racial and ethnic composition of its cohort. To answer our first research question, we categorized themes associated with racial differences in mindsets toward discretionary care and recorded the presence of associations in quantitative studies. To answer our second question, we identified whether quantitative studies address potential confounding with socioeconomic factors. There were no randomized trials, so no meta-analysis was performed.

RESULTS

In general, self-identified Black and Hispanic patients had a lower preference for hip and knee arthroplasty than self-identified White patients. Black patients were more likely to regard osteoarthritis as a natural and irremediable part of aging and prefer home remedies. Both Black and Hispanic patients valued support from religion and were relatively cost-conscious. Black and Hispanic patients had lower perception of benefit, were less familiar with the procedure, had higher levels of fear regarding surgery and recovery, and had more-limited trust in care. Generally, Black and Hispanic social networks tended to address these concerns, whereas White social networks were more likely to discuss the benefits of surgery. Thirteen of 14 quantitative studies considered and accounted for potential confounding socioeconomic variables in their analyses.

CONCLUSION

The observation that lower preference for discretionary arthroplasty among Black and Hispanic patients is independent from socioeconomic factors and is related to accommodation of aging, preference for agency (home remedies), greater consideration of costs, recovery concerns, and potential harms directs orthopaedic surgeons to find ways to balance equitable access to specialty care and discretionary surgery while avoiding undermining effective accommodation strategies. It is important not to assume that lower use of discretionary surgery represents poorer care or is a surrogate marker for discrimination.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient and Physician Perspectives on Discussing Addiction Recovery and Spirituality in the Primary Care Setting

BACKGROUND

Spirituality is an important component of recovery for many individuals with substance use disorder (SUD). However, few studies have compared patient and physician attitudes on spirituality in SUD recovery.

OBJECTIVE

This study investigates patient and physician beliefs about the role of spirituality in SUD recovery and about discussing spirituality in relationship to recovery in primary care settings.

DESIGN

Semi-structured interviews were conducted with primary care physicians recruited at two academic hospitals, and patients recruited from a faith-based residential therapeutic community. Interview transcripts were independently coded by two researchers and a grounded theory approach was used to generate themes that reflected participants' experiences.

KEY RESULTS

Interviews were conducted with 15 patients and 10 physicians. Patients had diverse views about the impact of spirituality on their SUD recovery, including positive, negative, and neutral. Patient and physician opinions on discussing spirituality in a primary care setting differed: most physicians felt positively towards this, believing that understanding their patients' spirituality helped them care for their patients as whole people. Many patients felt neutral, stating that they did not feel like these conversations were necessary for their care, and that they believed physicians preferred not to discuss spirituality in medical settings. Tolerance from both the patient and physician, open-ended questioning, and an individualized approach were identified as facilitators to effective discussions about spirituality and recovery.

CONCLUSIONS

Spirituality can have diverse effects on an individual's SUD recovery. Physicians endorsed the benefits of discussing spirituality in the context of their patients' recovery, while patients expressed reservations about engaging in these conversations with their physicians. This variation in perspectives highlights the need for additional research to understand the individual and structural factors that contribute to it, as well as best practices for engaging in effective, non-judgmental conversations about spirituality in recovery.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

Piloting web-based structural competency modules among internal medicine residents and graduate students in public health

Introduction

Fewer than half of internal medicine program directors report any health disparities curriculum. We piloted a web-based healthcare disparities module among internal medicine (IM) residents to test effectiveness and feasibility, compared to a convenient sample of graduate students enrolled in a public health equity course.

Methods

IM residents participated in an in-person session (module 1: introduction to racial and ethnic health disparities), but first, they completed a pre-module knowledge quiz. Two weeks later, they completed module 2: "unconscious associations" and a post-module knowledge quiz. For the control arm Yale School of Public Health (YSPH) students enrolled in a course on health disparities completed the pre-module knowledge quiz, module 1, and 2 as required by their course instructor.

Results

Forty-nine IM residents and 22 YSPH students completed the pre-module quiz and Module 1. The mean (SD) score out of 25 possible points for the IM residents on the pre-module quiz was 16.1/25 (2.8), and 16.6/25 (3.2) for YSPH students, with no statistically significant difference. Nineteen residents (38.8%) completed the post-module quiz with a mean score of 16.7/25 (2.2), Hedge's g =0.23, compared to 18 (81.8%) YSPH students, whose mean (SD) score was 19.5/25 (2.1), Hedge's g=1.05. YSPH students' post-module quiz average was statistically significantly higher than their pre-module test score, as well as the residents' post-module test (P < 0.001). In examining participants' responses to specific questions, we found that 51% (n = 25) of residents wrongly defined discrimination with an emphasis on attitudes and intent as opposed to actions and impact, compared to 22.7% (n = 5) YSPH students before the module, vs. 63.2% (n = 12) and 88.9% (n = 16) respectively after.

Conclusion

After completing a healthcare disparities course, graduate students in public health saw greater gains in knowledge compared to IM residents. Residents' responses showed knowledge gaps such as understanding discrimination, and highlight growth opportunity in terms of health equity education. Furthermore, embedding health equity education in required curricular activities may be a more effective approach.

Applying the NIA Health Disparities Research Framework to Identify Needs and Opportunities in Chronic Musculoskeletal Pain Research

Disparities in the experience of chronic musculoskeletal pain in the United States stem from a confluence of a broad array of factors. Organized within the National Institute on Aging Health Disparity Research Framework, a literature review was completed to evaluate what is known and what is needed to move chronic musculoskeletal pain research forward specific to disproportionately affected populations. Peer-reviewed studies published in English, on human adults, from 2000 to 2019, and conducted in the United States were extracted from PubMed and Web of Science. Articles were reviewed for key words that focused on underrepresented ethnic/race groups with chronic musculoskeletal pain applying health factor terms identified in the NIAHealth Disparity Research Framework four levels of analysis: 1) environmental, 2) sociocultural, 3) behavioral, and 4) biological. A total of 52 articles met inclusion criteria. There were limited publications specific to underrepresented ethnic/race groups with chronic musculoskeletal pain across all levels with particular research gaps under sociocultural and biological categories. Current limitations in evidence may be supplemented by a foundation of findings specific to the broader topic of "chronic pain" which provides guidance for future investigations. Study designs including a focus on protective factors and multiple levels of analyses would be particularly meritorious. PERSPECTIVE: Chronic musculoskeletal pain unequally burdens underrepresented ethnic/race groups. In order to move research forward and to systematically investigate the complex array of factors contributing toward health disparities, an organized approach is necessary. Applying the NIA Health Disparities Research Framework, an overview of the current state of evidence specific to chronic musculoskeletal pain and underrepresented ethnic/race groups is provided with future directions identified.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Patterns and Perceptions of Self-Management for Osteoarthritis Pain in African American Older Adults

OBJECTIVE

To explore and describe older African Americans' patterns and perceptions of managing chronic osteoarthritis pain.

METHODS

A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews.

SETTING

One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled.

RESULTS

Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins.

CONCLUSIONS

This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

"Bearing the Pain": The Experience of Aging African Americans With Osteoarthritis Pain

Studies document that osteoarthritis-related joint pain is more severe in African American older adults, but research on the personal experience of osteoarthritis pain self-management in this population is limited. Using a qualitative descriptive design, our objective was to extend our understanding of the experience of life with osteoarthritis pain. Eighteen African Americans (50 years and older) were recruited from Louisiana to participate in a single semi-structured, in-depth interview. A conventional content analysis revealed that “Bearing the pain” characterized how older African Americans dealt with osteoarthritis. Bearing the pain comprised three actions: adjusting to pain, sharing pain with others, and trusting God as healer. We discovered that a metapersonal experience subsumes the complex biopsychosocial-cultural patterns and the intricate interaction of self, others, and God in living with and managing osteoarthritis pain. Study findings have implications for application of more inclusive self-management frameworks and interventions.

Rationale and design of the Staying Positive with Arthritis (SPA) Study: A randomized controlled trial testing the impact of a positive psychology intervention on racial disparities in pain

Knee osteoarthritis is a painful, disabling condition that disproportionately affects African Americans. Existing arthritis treatments yield small to moderate improvements in pain and have not been effective at reducing racial disparities in the management of pain. The biopsychosocial model of pain and evidence from the positive psychology literature suggest that increasing positive psychological skills (e.g., gratitude, kindness) could improve pain and functioning and reduce disparities in osteoarthritis pain management. Activities to cultivate positive psychological skills have been developed and validated; however, they have not been tested in patients with osteoarthritis, their effects on racial differences in health outcomes have not been examined, and evidence of their effects on health outcomes in patients with other chronic illnesses is of limited quality. In this article we describe the rationale and design of Staying Positive with Arthritis (SPA) study, a randomized controlled trial in which 180 African American and 180 White primary care patients with chronic pain from knee osteoarthritis will be randomized to a 6-week program of either positive skill-building activities or neutral control activities. The primary outcomes will be self-reported pain and functioning as measured by the WOMAC Osteoarthritis Index. We will assess these primary outcomes and potential, exploratory psychosocial mediating variables at an in-person baseline visit and by telephone at 1, 3, and 6months following completion of the assigned program. If effective, the SPA program would be a novel, theoretically-informed psychosocial intervention to improve quality and equity of care in the management of chronic pain from osteoarthritis.

Pain Management for Older African Americans in the Perianesthesia Setting: The "Eight I's"

National legislation (Affordable Care Act) emphasizes quality and equitable pain care for all patient populations, but frequently, pain management is not effective and equitable in African American (AA) elders, placing them at higher risk for severe pain and persistent pain. Research shows that AAs are less likely to receive guideline-based pain care. This underscores the need for perianesthesia nurses to be knowledgeable and capable of integrating cultural practices and evidence-based recommendations into their care of older AAs to ensure adequate pain management in this vulnerable population. This article describes differences and disparities in pain management in AA older adults and provides a cultural framework to guide perianesthesia pain management.

Racial/Ethnic Disparity in Rates and Outcomes of Total Joint Arthroplasty

Racial/ethnic disparity in total joint arthroplasty (TJA) has grown over the last two decades as studies have documented the widening gap between Blacks and Whites in TJA utilization rates despite the known benefits of TJA. Factors contributing to this disparity have been explored and include demographics, socioeconomic status, patient knowledge, patient preference, willingness to undergo TJA, patient expectation of post-arthroplasty outcome, religion/spirituality, and physician-patient interaction. Improvement in patient knowledge by effective physician-patient communication and other methods can possibly influence patient's perception of the procedure. Such interventions can provide patient-relevant data on benefits/risks and dispel myths related to benefits/risks of arthroplasty and possibly reduce this disparity. This review will summarize the literature on racial/ethnic disparity on TJA utilization and outcomes and the factors underlying this disparity.

Determinants of patient preferences for total knee replacement: African-Americans and whites

Introduction

Patient preferences contribute to marked racial disparities in the utilization of total knee replacement (TKR). The objectives of this study were to identify the determinants of knee osteoarthritis (OA) patients’ preferences regarding TKR by race and to identify the variables that may mediate racial differences in willingness to undergo TKR.

Methods

Five hundred fourteen White (WH) and 285 African-American (AA) patients with chronic knee pain and radiographic evidence of OA participated in the study. Participants were recruited from the community, an academic medical center, and a Veterans Affairs hospital. Structured interviews were conducted to collect socio-demographics, disease severity, socio-cultural determinants, and treatment preferences. Logistic regression was performed, stratified by race, to identify determinants of preferences. Clinical and socio-cultural factors were entered simultaneously into the models. Stepwise selection identified factors for inclusion in the final models (p < 0.20).

Results

Compared to WHs, AAs were less willing to undergo TKR (80 % vs. 62 %, respectively). Better expectations regarding TKR surgery outcomes determined willingness to undergo surgery in both AAs (odds ratio (OR) 2.08, 95 % confidence interval (CI) 0.91-4.79 for 4^th vs. 1^st quartile) and WHs (OR 5.11, 95 % CI 2.31-11.30 for 4^th vs. 1^st quartile). Among AAs, better understanding of the procedure (OR 1.80, 95 % CI 0.97-3.35), perceiving a short hospital course (OR 0.81, 95 % CI 0.58-1.13), and believing in less post-surgical pain (OR 0.73, 95 % CI 0.39-1.35) and walking difficulties (OR 0.66, 95 % CI 0.37-1.16) also determined willingness. Among WHs, having surgical discussion with a physician (OR 1.96, 95 % CI 1.05-3.68), not ever receiving surgical referral (OR 0.56, 95 % CI 0.32-0.99), and higher trust in the healthcare system (OR 1.58, 95 % CI 0.75-3.31 for 4^th vs. 1^st quartile) additionally determined willingness. Among the variables considered, only knowledge-related matters pertaining to TKR attenuated the racial difference in knee OA patients’ treatment preference.

Conclusions

Expectations of surgical outcomes influence preference for TKR in all patients, but clinical and socio-cultural factors exist that shape marked racial differences in preferences for TKR. Interventions to reduce or eliminate racial disparities in the utilization of TKR should consider and target these factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0864-2) contains supplementary material, which is available to authorized users.

Do patients want doctors to talk about spirituality? A systematic literature review

OBJECTIVE

The aim of this systematic literature review was to ascertain the patient perspective regarding the role of the doctor in the discussion of spirituality.

METHODS

We conducted a systematic search in ten databases from inception to January 2015. Eligible papers reported on original research including patient reports of discussion of spirituality in a medical consultation. Papers were separated into qualitative and quantitative for the purposes of analysis and quality appraisal with QualSyst. Papers were merged for the final synthesis.

RESULTS

54 studies comprising 12,327 patients were included. In the majority of studies over half the sample thought it was appropriate for the doctor to enquire about spiritual needs in at least some circumstances (range 2.1-100%, median 70.5%), but patient preferences were not straightforward.

CONCLUSION

While a majority of patients express interest in discussion of religion and spirituality in medical consultations, there is a mismatch in perception between patients and doctors regarding what constitutes this discussion and therefore whether it has taken place.

PRACTICE IMPLICATIONS

This review demonstrated that many patients have a strong interest in discussing spirituality in the medical consultation. Doctors should endeavor to identify which patients would welcome such conversations.

African Americans’ Perceptions of Pain and Pain Management

Purpose: The purpose of this systematic review is to explore the perceptions of acute, persistent, and disease-specific pain and treatment options held by adult African Americans. Underassessment and undermanagement of pain in African Americans has been well documented; however, the cultural continuum of pain perceptions and their influence on pain assessment and management has not been synthesized. Design: Electronic database searches of the Cumulative Index for Nursing and Allied Health Literature and PubMed, Web-based searches of the pain-specific journals plus a manual search of reference lists identified 41 relevant articles addressing perceptions of pain and/or pain management. Findings: Analysis of the literature revealed six themes: (a) meaning of pain, (b) description of pain, (c) coping with pain, (d) impact of pain, (e) patient–provider relationship, and (f) treatment approaches. Conclusion: These findings warrant further research and indicate the need for more precise evaluation of pain in African Americans, highlighting an imperative to incorporate cultural patterns into pain management practice and education.

Sociodemographic and clinical predictors of compliance with antidepressants for depressive disorders: systematic review of observational studies

BACKGROUND

The literature shows that compliance with antidepressant treatment is unsatisfactory. Several personal and disease-related variables have been shown to be related to compliance behavior. The objective of this study was to review the literature about sociodemographic and clinical predictors of compliance in patients with depressive disorders.

METHODS

The Medline, Embase, Cochrane Central, PsycInfo, and Cinahl databases were searched until May 2012. Studies that analyzed sociodemographic and clinical predictors or correlates of compliance in patients with depressive disorder were included. A quantitative synthesis was not performed because of the heterogeneity and availability of the data reported. For similar reasons, the results were not classified according to the different phases of treatment. The search was limited to studies published in English and Spanish.

RESULTS

Thirty-two studies fulfilled the inclusion criteria. The most consistent associations with compliance were found for age (older patients showed more compliance) and race (white patients were more likely to adhere to treatment than minority ethnic groups). Few studies assessed clinical factors, and the most plausible predictors of compliance were certain comorbidities and substance abuse. Severity of depression did not play an important role in predicting compliance.

CONCLUSION

The impact of the variables studied on compliance behavior appeared to be inconsistent. Identifying potential predictors of compliance with antidepressant treatment is important, both for the routine practice of the mental health professional and for refining interventions to enhance adherence and target them to specific populations at risk of noncompliance.

Predictors of overnight hospital admission in older African American and Caucasian Medicare beneficiaries

BACKGROUND

Potential disparities in health care utilization were examined using overnight hospitalization data from the University of Alabama at Birmingham Study of Aging, a longitudinal investigation of a stratified sample of Medicare beneficiaries.

METHODS

Racial differences in self-reported surgical and nonsurgical overnight hospital admissions were examined using Cox proportional hazards models. Andersen's Behavioral Model provided the conceptual framework to identify other potential predictors of admission.

RESULTS

Nine hundred and forty-two participants, 50.1% African American, provided data at baseline and at least one follow-up assessment (mean age = 75.3 years, range: 65-106). African Americans were less likely to utilize surgical admissions compared with Caucasians in a bivariate model (hazard ratio = 0.63, 95% confidence interval = 0.41-0.98). This effect was not significant after controlling for demographics and self-reported physical health. Additional bivariate predictors of surgical admission were intact mental status, having private insurance, and higher education. African Americans were less likely to utilize nonsurgical admissions in both bivariate (hazard ratio = 0.74, 95% confidence interval = 0.59-0.93) and covariate-adjusted models (hazard ratio = 0.64, 95% confidence interval = 0.50-0.84). This effect was significantly stronger for men than for women, with African American men only 0.50 times as likely as Caucasian men to report a nonsurgical admission. Other bivariate predictors of nonsurgical admission were increased age, poor physical health, negative psychological characteristics, higher levels of social support, and low perceived discrimination.

CONCLUSION

Underutilization of services has been linked to increased mortality in African Americans. Modifications in mutable domains associated with service utilization such as perceived discrimination, social support, and having private insurance may be beneficial.

Orthopedic communication about osteoarthritis treatment: Does patient race matter?

OBJECTIVE

To understand racial disparities in the use of total joint replacement, we examined whether there were racial differences in patient-provider communication about treatment of chronic knee and hip osteoarthritis in a sample of African American and white patients referred to Veterans Affairs orthopedic clinics.

METHODS

Audio recorded visits between patients and orthopedic surgeons were coded using the Roter Interaction Analysis System and the Informed Decision-Making model. Racial differences in communication outcomes were assessed using linear regression models adjusted for study design, patient characteristics, and clustering by provider.

RESULTS

The sample (n = 402) included 296 white and 106 African American patients. Most patients were men (95%) and ages 50-64 years (68%). Almost half (41%) reported an income <$20,000. African American patients were younger and reported lower incomes than white patients. Visits with African American patients contained less discussion of biomedical topics (β = -9.14; 95% confidence interval [95% CI] -16.73, -1.54) and more rapport-building statements (β = 7.84; 95% CI 1.85, 13.82) than visits with white patients. However, no racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, patient activation/engagement statements, physician verbal dominance, display of positive affect by patients or providers, or discussion related to informed decision making.

CONCLUSION

In this sample, communication between orthopedic surgeons and patients regarding the management of chronic knee and hip osteoarthritis did not, for the most part, vary by patient race. These findings diminish the potential role of communication in Veterans Affairs orthopedic settings as an explanation for well-documented racial disparities in the use of total joint replacement.

Defining racial and ethnic disparities in THA and TKA

BACKGROUND

For minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.

QUESTIONS/PURPOSES

We therefore (1) defined utilization disparities for total joint arthroplasty in racial and ethnic minorities, (2) delineated patient and provider factors contributing to the lower total joint arthroplasty utilization, and (3) discussed potential interventions and future research that may increase total joint arthroplasty utilization by racial and ethnic minorities.

METHODS

We searched the MEDLINE database and identified 67 articles, 21 of which we excluded. By searching Google and Google Scholar and reference lists of the included articles, we identified 40 articles for this review. Utilization disparities were defined by documented lower utilization of THA or TKA in specific racial or ethnic groups.

RESULTS

Lower utilization of THA and TKA among some racial and ethnic minority groups (African Americans, Hispanics) is not explained by decreased disease prevalence or disability. At least some utilization disparities are independent of income, geographic location, education, and insurance status. Causal factors related to racial and ethnic disparities may be related in part to patient factors such as health literacy, trust, and preferences. Provider unconscious or conscious biases or beliefs also play a role in at least some healthcare disparities.

CONCLUSIONS

Racial and ethnic THA and TKA utilization disparities exist. These disparities are not explained by lower disease prevalence. The existing data suggest patient education, improved health literacy regarding THA and TKA, and a patient-provider relationship leading to improved trust would be beneficial. Research providing a better understanding of the root causes of these disparities is needed.

Investigating racial differences in coping with chronic osteoarthritis pain

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (beta = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.

Development of a decision aid to address racial disparities in utilization of knee replacement surgery

OBJECTIVE

Previous studies suggest that poorer knowledge and expectations about surgical outcomes may be responsible for low rates of total knee replacement (TKR) among African American males. The goal of this study was to pilot test the scope, acceptability, and efficacy of an educational videotape and tailored TKR decision aid designed to reduce disparities in TKR knowledge and expectations.

METHODS

African American and Caucasian male veteran volunteers ages 55-85 years with moderate to severe knee osteoarthritis (OA) were recruited. During group meetings, patients viewed a video about knee OA treatments and were provided a personalized arthritis report that presented predicted patient outcomes should they decide to undergo TKR. Patients completed baseline and postintervention questionnaires that included an adapted Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) instrument to measure post-TKR expectations (0-100 scale with higher scores reflecting poorer outcomes).

RESULTS

A total of 102 patients (54 African American, 48 Caucasian) completed the baseline survey and 64 patients attended the intervention. There were no significant differences by race between patients completing and those dropping out of the study. At baseline (n = 102), African American patients expressed lower expectations about post-TKR outcomes than did Caucasian patients for both pain (WOMAC score 41 versus 34; P = 0.18) and physical function expectations (WOMAC score 38 versus 30; P = 0.13). Among African Americans who underwent the intervention, expected pain and physical function improved to 31 (P = 0.04 versus baseline) and 30 (P = 0.09 versus baseline), respectively. Caucasian patients' expectations changed little.

CONCLUSION

Disparities in baseline knowledge and expectations about TKR may be improved with the combined educational video and tailored decision aid.