Total Knee Arthroplasty (TKA) and Total Joint Replacement (TJR) procedures are customarily used to surgically reconstruct or replace a joint. This procedure is frequently performed as a resolution for functional debilitation in the knee and knee pain management. Arthritis, gout, trauma to the knee joint, death of bone at or around the joint, and knee deformity and pain are common clinical indicators of a Total Knee Arthroplasty. Regardless of the heterogeneous applicability of knee procedures like TKA and TJR for many medical conditions, it is still disproportionately preferred by the white patient population. There are several factors that propagate these racial disparities in the patient pool that qualify and then further opt for Total Knee Arthroplasty/Total Joint Replacement procedures. This  differential usage of TKA/TJR procedures amongst communities are a product of cultural views on injury management, financial considerations, and injury susceptibility as a consequence of lifestyle tendencies. These promote an institutionalized clinical barrier for underprivileged, minority communities to seek out proper treatment for knee injuries.

Research has repeatedly shown that minority patients have a lower preference for electing to undergo joint replacement procedures compared to non-hispanic white patients. This phenomenon can be attributed to commonly held views on disease management and the perceived feasibility of surgical options in minority communities, [1]. The primary consideration among medical providers when analyzing the disparities among patients in the context of TKA and TJR procedures should be the cultural values of affected communities for these preference-sensitive procedures. Communities have been socialized into varying perspectives on appropriate strategies to manage pain and injuries; this is a frequent product of apprehensive attitudes of American healthcare by minority patients. For example,  in univariate analyses, Blacks and Hispanics reported higher levels of physician distrust than did Whites [6]. Physician distrust and self-management of pain are the two main contributing beliefs that many minority groups hold as a result of their unsure faith in American healthcare. Minority groups are thus less likely to seek out “elective” procedures; TJR is considered elective in part because it is rarely performed in urgent settings [3]

The patient has to also want the surgery for it to be recommended. This thinking complicates the efforts to universally equalize the utilization disparity for these procedures. It has been demonstrated that African Americans have lower rates of preference for this particular procedure; this can likely be attributed to a number of intersectional factors. Lower utilization rates of TKA/TJR in African American communities mean that fewer African American patients are exposed to friends and family members undergoing TJR with positive outcomes. The racial variation between individual’s preference for a TKA/TJR procedure can be seen in the exposure of these individuals to differing sociocultural beliefs. 

The proclivity of minority communities to forgo preference-sensitive joint replacement surgeries is not exclusively a cultural phenomenon; there is a distinct interaction with the socioeconomic position of many minority communities. There are data to suggest that minority patients receive TJR procedures at low-volume or at low-quality hospitals compared to nonminority patients; a factor that can likely be traced to socioeconomic differences amongst minority and white communities [3]. This difference in quality of medical care can be seen explicitly in the difference between surgical outcomes among patients of minority communities vs. white communities. The US black population may derive less benefit from TKA than whites as measured by HRQOL (health related quality of life), pain, function, and satisfaction [1]. In the United States, 39 percent of African-American individuals and 33 percent of Latino individuals are living in poverty, which is more than double the 14 percent poverty rate for non-Latino, White, and Asian individuals [4]. In addition, the Black and white individuals living in communities with little poverty have similar patient-reported TKA outcomes, whereas in communities with high levels of poverty, there are important racial disparities, indicating a financial facet of patient care in TKA procedures [2]. Poverty also is associated with poor pain and function after TKA [1]. By linking individual-level registry data that includes self-reported outcomes and individual level socioeconomic variables to area-based census tract poverty levels, a study was able to analyze the interaction between race and community poverty and patient-reported outcomes after TKA. The study found that black patients have worse pain and function two years after TKA than whites, and the difference is also strongly associated with census tract poverty [1]. This makes an elective procedure for non-urgent care a lesser financial priority in a minority group’s schema of  surgical pain/disease management. 

A secondary consideration amongst providers is the influence of career and lifestyle choices and the disproportionate presence of minorities in positions that can result in knee-injuries. This makes racial disparities amongst a TKA/TJR procedure even more indicative of a symptomatic neglect of patient level factors that influence quality of care by practitioners. Studies show that racial/ethnic minorities have disproportionately higher rates of disease, death, and disability, than their white counterparts. Moreover, while arthritis-related activity, work limitations, and severe pain disproportionately impact African American patients compared to White patients; numerous studies in the last 10 to 15 years have documented marked racial disparity in the utilization of TJR (Total Joint Replacement), which indicates a lifestyle disparity that is further linked with race [3]. Hispanic workers, particularly recent immigrants, are at particularly high risk of occupational illness and injury. Racial/ethnic minorities also have disproportionately higher rates of fatal occupational injuries [5]. The frequent state of occurence of these injuries among minority populations causes the significance of the injury to dilute itself. The minority population contains untreated knee injuries in a high incidence,  which result in individuals that are less likely to seek out a preference-sensitive procedure, but rather opting to use alternate coping mechanisms to relieve symptoms. 

Overall, the results of this multifaceted analysis underscore how important it is that public health research examine how intersecting systems of inequality in work and patient care considerations affect the availability of a TKA/TJR procedure that can help with debilitating pain and physical function. These are among the several factors that push the racial disparities in the context of Total Knee Arthroplasty/Total Joint Replacement surgeries, promoting an institutionalized barrier for certain communities to seek out proper treatment. In terms of clinical implications, the neglect of racial considerations and cultural variations in treatment preferences is linked to long-term illness/injury/assault for minority and low-income individuals. Thus, medical practitioners would better serve their patients by focusing on altering viewpoints on elective surgeries and addressing misconstrued perspectives of negative surgical outcomes among these minority/low-income communities.

References:

1. Goodman  SM, Parks  ML, McHugh  K,  et al.  Disparities in outcomes for African Americans and whites undergoing total knee arthroplasty: a systematic literature review.   J Rheumatol. 2016;43(4):765-770. https://doi.org/10.3899/jrheum.150950

2. Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Differences in expectation on outcome mediate African-American/White differences in “willingness” to consider joint replacement. Arthritis Rheum. 2002;46(9):2429–2435  https://doi.org/10.1002/1529-0131(200108)45:4%3C340::AID-ART346%3E3.0.CO;2-5

3. Jha AK, Fisher ES, Li Z, Orav EJ, Epstein AM. Racial trends in the use of major procedures among the elderly. N Engl J Med. 2005;353:683–691 https://doi.org/10.1056/nejmsa050672

4. Reeves, R., Rodrigue, E., & Kneebone, E. (2016). Five evils: Multidimensional poverty and race in America. Retrieved from https://doi.org/10.1056/nejmsa050672

5. Shannon, Candice A et al. “Race, racial discrimination, and the risk of work-related illness, injury, or assault: findings from a national study.” Journal of occupational and environmental medicine vol. 51,4 (2009): 441-8. http://dx.doi.org/10.1097/JOM.0b013e3181990c17

6. Armstrong, Katrina et al. “Racial/ethnic differences in physician distrust in the United States.” American journal of public health vol. 97,7 (2007): 1283-9. https://dx.doi.org/10.2105%2FAJPH.2005.080762

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