Preferences for arthritis care among urban African Americans: "I don't want to be cut".

Despite greater disability from knee osteoarthritis among Blacks, Whites are 3-5 times more likely to have total knee replacement (TKR). The authors explored whether beliefs among Blacks about arthritis and surgery contribute to this disparity. Ninety-four Blacks, ages 50 to 89, with knee arthritis underwent semistructured qualitative interviews regarding disability, beliefs about arthritis, beliefs about TKR, and treatment preferences. Content analyses yielded 6 themes: preference for natural remedies, negative expectations of surgery, beliefs about God's control, preference for continuing in their current state, relationships with specialists, and fear of surgery or death. Given its high levels of disability, this cohort had low expectations of TKR. Culturally sensitive educational programs might improve patient altitudes and beliefs regarding TKR, ultimately increasing appropriate usage.

Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture.

We conducted a randomized controlled trial to assess the efficacy and safety of a multiple-component intervention designed to improve functional recovery after hip fracture. One hundred seventy-six patients who underwent surgery for a primary unilateral hip fracture were assigned randomly to receive usual care (control arm, n = 86) or a brief motivational videotape, supportive peer counseling, and high-intensity muscle-strength training (intervention arm, n = 90). Between-group differences on the physical functioning, role-physical, and social functioning domains of the SF-36 were assessed postoperatively at 6 months. At the end of the trial, 32 intervention and 27 control patients (34%) completed the 6-month outcome assessment. Although patient compliance with all three components of the intervention was uneven, over 90% of intervention patients were exposed to the motivational videotape. Intervention patients experienced a significant (P = 0.03) improvement in the role-physical domain (mean change, -11 +/- 33) compared to control patients (mean change, -37 +/- 41). Change in general health (P = 0.2) and mental health (P = 0.1) domain scores was also directionally consistent with the study hypothesis. Although our findings are consistent with previous reports of comprehensive rehabilitation efforts for hip fracture patients, the trial was undermined by high attrition and the possibility of self-selection bias at 6-month follow-up. We discuss the methodological challenges and lessons learned in conducting a randomized controlled trial that sought to implement and assess the impact of a complex intervention in a population that proved difficult to follow up once they had returned to the community.