Ethnic and Racial Factors Influencing Well-being, Perceived Pain, and Physical Function After Primary Total Joint Arthroplasty

  • Carlos J. Lavernia
  • Jose C. Alcerro
  • Juan S. Contreras
  • Mark D. Rossi
Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium

Abstract

Background

Studies suggest, even when controlling for disease severity, socioeconomic status, education, and access to care, racial and ethnic minorities receive lower-quality health care and have worse perceived pain and function before and after total joint arthroplasty.

Question/purposes

We evaluated the influence of race and ethnicity on well-being, pain, and function after total joint arthroplasty and determined whether race, ethnicity, sex, and joint involvement influenced perceived function and pain after total joint arthroplasty.

Patients and Methods

We retrospectively reviewed the records of 1749 patients receiving total joint arthroplasty (739 hips and 1010 knees). Sixty-eight percent were women, with a mean age of 65 years at followup. We assessed patients preoperatively and at a minimum of 2 years (mean, 5.1 years; range, 2–16 years) on perceived well-being, function, and pain, as well as clinical assessment tools. Also, we assessed the behavior of dependent measures between groups over time.

Results

Preoperatively, in both TKA and THA candidates, African American patients presented with worse scores. Postoperatively, all patients had substantial improvement, yet African Americans who had TKA or THA continued to have worse scores on some measures. In both TKA and THA, women had worse scores.

Conclusions

Racial and ethnic minorities undergoing hip and knee arthroplasty appear to have worse patient-perceived outcomes (well-being, pain, and function) when compared to whites. This discrepancy is most pronounced for African Americans.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

References

  1. 1.
    Alicea J. Scoring systems and their validation for the arthritic knee. In: Insall JN, Scott WN, eds. Surgery of the Knee. 3rd ed. New York, NY: Churchill Livingstone; 2001:1507–1515Google Scholar
  2. 2.
    Ang DC, Ibrahim SA, Burant CJ, Siminoff LA, Kwoh CK. Ethnic differences in the perception of prayer and consideration of joint arthroplasty. Med Care. 2002;40:471–476.PubMedCrossRefGoogle Scholar
  3. 3.
    Ang DC, Monahan PO, Cronan TA. Understanding ethnic disparities in the use of total joint arthroplasty: application of the health belief model. Arthritis Rheum. 2008;59:102–108.PubMedCrossRefGoogle Scholar
  4. 4.
    Arocho R, McMillan CA, Sutton-Wallace P. Construct validation of the USA-Spanish version of the SF-36 health survey in a Cuban-American population with benign prostatic hyperplasia. Qual Life Res. 1998;7:121–126.PubMedCrossRefGoogle Scholar
  5. 5.
    Baron JA, Barrett J, Katz JN, Liang MH. Total hip arthroplasty: use and select complications in the US Medicare population. Am J Public Health. 1996;86:70–72.PubMedGoogle Scholar
  6. 6.
    Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92:792–798.PubMedCrossRefGoogle Scholar
  7. 7.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840.PubMedGoogle Scholar
  8. 8.
    Blustein J. Who is accountable for racial equity in health care? JAMA. 2008;299:814–816.PubMedCrossRefGoogle Scholar
  9. 9.
    Bourne RB, Rorabeck CH. A critical look at cementless stems: taper designs and when to use alternatives. Clin Orthop Relat Res. 1998;355:212–223.PubMedCrossRefGoogle Scholar
  10. 10.
    Bozic KJ, Saleh KJ, Rosenberg AG, Rubash HE. Economic evaluation in total hip arthroplasty: analysis and review of the literature. J Arthroplasty. 2004;19:180–189.PubMedCrossRefGoogle Scholar
  11. 11.
    Byrne MM, O’Malley KJ, Suarez-Almazor ME. Ethnic differences in health preferences: analysis using willingness-to-pay. J Rheumatol. 2004;31:1811–1818.PubMedGoogle Scholar
  12. 12.
    Constantinescu F, Goucher S, Weinstein A, Fraenkel L. Racial disparities in treatment preferences for rheumatoid arthritis. Med Care. 2009;47:350–355.PubMedCrossRefGoogle Scholar
  13. 13.
    d’Aubigné RM, Postel M. The Classic. Functional results of hip arthroplasty with acrylic prosthesis. 1954. Clin Orthop Relat Res. 2009;467:7–27.PubMedCrossRefGoogle Scholar
  14. 14.
    Demey G, Servien E, Pinaroli A, Lustig S, Ait Si Selmi T, Neyret P. The influence of femoral cementing on perioperative blood loss in total knee arthroplasty: a prospective randomized study. J Bone Joint Surg Am. 2010;92:536–541.PubMedCrossRefGoogle Scholar
  15. 15.
    Dunlop DD, Song J, Manheim LM, Chang RW. Racial disparities in joint replacement use among older adults. Med Care. 2003;41:288–298.PubMedGoogle Scholar
  16. 16.
    Emejuaiwe N, Jones AC, Ibrahim SA, Kwoh CK. Disparities in joint replacement utilization: a quality of care issue. Clin Exp Rheumatol. 2007;25:44–49.PubMedGoogle Scholar
  17. 17.
    Escalante A, Espinosa-Morales R, del Rincon I, Arroyo RA, Older SA. Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum. 2000;43:390–399.PubMedCrossRefGoogle Scholar
  18. 18.
    Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health. 1993;83:948–954.PubMedCrossRefGoogle Scholar
  19. 19.
    Figaro MK, Williams-Russo P, Allegrante JP. Expectation and outlook: the impact of patient preference on arthritis care among African Americans. J Ambul Care Manage. 2005;28:41–48.PubMedGoogle Scholar
  20. 20.
    Gandhi R, Dhotar H, Razak F, Tso P, Davey JR, Mahomed NN. Predicting the longer term outcomes of total knee arthroplasty. Knee. 2010;17:15–18.PubMedCrossRefGoogle Scholar
  21. 21.
    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 Rheum. 2008;59:730–737.PubMedCrossRefGoogle Scholar
  22. 22.
    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.PubMedGoogle Scholar
  23. 23.
    Holtzman J, Saleh K, Kane R. Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty. Med Care. 2002;40:461–470.PubMedCrossRefGoogle Scholar
  24. 24.
    Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Differences in expectations of outcome mediate African American/white patient differences in “willingness” to consider joint replacement. Arthritis Rheum. 2002;46:2429–2435.PubMedCrossRefGoogle Scholar
  25. 25.
    Ibrahim SA, Stone RA, Han X, Cohen P, Fine MJ, Henderson WG, Khuri SF, Kwoh CK. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arthritis Rheum. 2005;52:3143–3151.PubMedCrossRefGoogle Scholar
  26. 26.
    Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14.PubMedGoogle Scholar
  27. 27.
    Kaplan RM, Bush JW. Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol. 1982;1:61–80.CrossRefGoogle Scholar
  28. 28.
    Katz BP, Freund DA, Heck DA, Dittus RS, Paul JE, Wright J, Coyte P, Holleman E, Hawker G. Demographic variation in the rate of knee replacement: a multi-year analysis. Health Serv Res. 1996;31:125–140.PubMedGoogle Scholar
  29. 29.
    Lavernia CJ, Alcerro JC, Rossi MD. Fear in arthroplasty surgery: the role of race. Clin Orthop Relat Res. 2010;468:547–554.PubMedCrossRefGoogle Scholar
  30. 30.
    Lavernia CJ, Lee D, Sierra RJ, Gomez-Marin O. Race, ethnicity, insurance coverage, and preoperative status of hip and knee surgical patients. J Arthroplasty. 2004;19:978–985.PubMedCrossRefGoogle Scholar
  31. 31.
    Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, Dellagrammaticas D, Horrocks M, Liapis C, Banning AP, Gough M, Gough MJ. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372:2132–2142.PubMedCrossRefGoogle Scholar
  32. 32.
    MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Serv Res. 1996;31:623–638.PubMedGoogle Scholar
  33. 33.
    Parsley BS, Bertolusso R, Harrington M, Brekke A, Noble PC. Influence of gender on age of treatment with TKA and functional outcome. Clin Orthop Relat Res. 2010;468:1759–1764.PubMedCrossRefGoogle Scholar
  34. 34.
    Quintana JM, Escobar A, Aguirre U, Lafuente I, Arenaza JC. Predictors of health-related quality-of-life change after total hip arthroplasty. Clin Orthop Relat Res. 2009;467:2886–2894.PubMedCrossRefGoogle Scholar
  35. 35.
    Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5–14.PubMedCrossRefGoogle Scholar
  36. 36.
    Sandler RS, Halabi S, Baron JA, Budinger S, Paskett E, Keresztes R, Petrelli N, Pipas JM, Karp DD, Loprinzi CL, Steinbach G, Schilsky R. A randomized trial of aspirin to prevent colorectal adenomas in patients with previous colorectal cancer. N Engl J Med. 2003;348:883–890.PubMedCrossRefGoogle Scholar
  37. 37.
    Singh JA, O’Byrne M, Harmsen S, Lewallen D. Predictors of moderate-severe functional limitation after primary total knee arthroplasty (TKA): 4701 TKAs at 2-years and 2935 TKAs at 5-years. Osteoarthritis Cartilage. 2010;18:515–521.PubMedCrossRefGoogle Scholar
  38. 38.
    Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359.PubMedCrossRefGoogle Scholar
  39. 39.
    Slover JD, Walsh MG, Zuckerman JD. Sex and race characteristics in patients undergoing hip and knee arthroplasty in an urban setting. J Arthroplasty. 2010;25:576–580.PubMedCrossRefGoogle Scholar
  40. 40.
    Wilson MG, May DS, Kelly JJ. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis. 1994;4:57–67.PubMedGoogle Scholar
  41. 41.
    Zheng JP, Kang J, Huang SG, Chen P, Yao WZ, Yang L, Bai CX, Wang CZ, Wang C, Chen BY, Shi Y, Liu CT, Chen P, Li Q, Wang ZS, Huang YJ, Luo ZY, Chen FP, Yuan JZ, Yuan BT, Qian HP, Zhi RC, Zhong NS. Effect of carbocisteine on acute exacerbation of chronic obstructive pulmonary disease (PEACE Study): a randomised placebo-controlled study. Lancet. 2008;371:2013–2018.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Carlos J. Lavernia
    • 1
    • 2
  • Jose C. Alcerro
    • 2
  • Juan S. Contreras
    • 2
  • Mark D. Rossi
    • 3
  1. 1.Orthopaedic Institute at Mercy HospitalMiamiUSA
  2. 2.Arthritis Surgery Research Foundation, IncMiamiUSA
  3. 3.Department of Physical TherapyFlorida International UniversityMiamiUSA

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