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Original Investigation
January 18, 2017

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

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
  • 2Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 3Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
  • 4Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
  • 5Department of Orthopedic Surgery and Sports Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
JAMA Surg. 2017;152(1):e164225. doi:10.1001/jamasurg.2016.4225
Key Points

Question  Does patient education with a decision aid improve access to total knee replacement surgery for black patients with end-stage osteoarthritis of the knee?

Findings  In this randomized clinical trial of 336 individuals, a patient-centered educational intervention using validated decision aid significantly increased receipt of total knee replacement surgery for black patients with end-stage osteoarthritis of the knee.

Meaning  Patient-centered educational tools such as decision aids might help reduce racial disparities in access to preference-sensitive surgical treatments such as total knee replacement.

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

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