Does Physical Activity Confound Race Differences in Osteoarthritis-Related Functional Limitation?

OBJECTIVE: This study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)-related functional limitation. METHODS: OA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self-reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68. RESULTS: African American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to vigorous physical activity, the association between AA race and inability to walk a community walking speed slightly decreased (from relative risk [RR] 2.15, 95% confidence interval [95% CI] 1.64-2.81, to RR 1.99, 95% CI 1.51-2.61). Association between AA race and other measures of functional limitation mildly decreased (slow walking speed: from RR 2.06, 95% CI 1.40-3.01, to RR 1.82, 95% CI 1.25-2.63; low physical functioning: from RR 3.44, 95% CI 1.96-6.03, to RR 3.10, 95% CI 1.79-5.39). When further adjusted for demographic and other clinical variables, only the association between race and low physical functioning (WOMAC) significantly decreased and no longer met statistical significance. CONCLUSION: Greater physical activity is unlikely to completely make up for race differences in OA-related functional limitation, and other barriers to health equity need to be addressed.

Renin-Angiotensin System-Modifying Antihypertensive Drugs Can Reduce the Risk of Cardiovascular Complications in Lupus: A Retrospective Cohort Study.

BACKGROUND: Patients with systemic lupus erythematosus have a higher incidence of cardiovascular disease than the general population. Antihypertensive drugs that modify the renin-angiotensin system (RAS) are used to protect renal function in lupus nephritis and may also have extrarenal effects that lower cardiovascular disease risk due to their anti-inflammatory properties. In this study, we compared the effects of RAS vs non-RAS antihypertensive drugs on cardiovascular disease incidence in patients with lupus. METHODS: Using a medical insurance claims dataset, 220,168 patients with lupus were identified, of which 31,647 patients (4018 patients prescribed RAS drugs, 27,629 patients prescribed non-RAS drugs) were eligible for the study. Patients had a mean age of 46.1 years, were 93.0% female, and healthy (96.9% Charlson Comorbidity Index score 0-4). Patients in the 2 drug groups were propensity score matched using demographic data, risk factors, and comorbidities. RESULTS: Use of RAS vs non-RAS drugs lowered the relative risk (RR) of diagnosis of cardiovascular disease (RR 0.80; 95% confidence interval [CI], 0.74-0.87), which was more pronounced after propensity score matching (RR 0.62; 95% CI, 0.57-0.68). The decreased risk in cardiovascular disease occurred regardless of lupus nephritis status (with lupus nephritis: RR 0.51; 95% CI, 0.39-0.65; without lupus nephritis: RR 0.65; 95% CI, 0.59-0.72). RAS-modifying therapies significantly increased cardiovascular disease-free survival probability over a 5-year period (86.0% vs 78.3% probability). CONCLUSIONS: RAS-modifying drugs reduced the risk of cardiovascular disease in patients with systemic lupus erythematosus in this dataset. These findings have the potential to impact clinical decision-making with regards to hypertension management in patients with lupus.

Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review.

Background: Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments. Objectives: The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA. Data sources and methods: A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results: The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations. Conclusion: This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.

Use of Complementary and Alternative Therapy for Knee Osteoarthritis: Race and Gender Variations.

OBJECTIVE: To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors). METHODS: A secondary analysis of cross-sectional data was conducted. The sample included Veterans Affairs patients 50 years of age or older with symptomatic knee OA. Current use of various CAM therapies was assessed at baseline. Logistic regression models were used to compare race and gender differences in the use of specific CAMs. RESULTS: The sample included 517 participants (52.2% identified as African American [AA]; 27.1% identified as female). After adjusting for demographic and clinical factors, AA participants, compared with white participants, were less likely to use joint supplements (odds ratio [OR]: 0.53; 95% confidence interval [CI], 0.31-0.90]); yoga, tai chi, or pilates (OR: 0.39; 95% CI: 0.19-0.77); and chiropractic care (OR: 0.51; 95% CI: 0.26-1.00). However, they were more likely to participate in spiritual activities (OR: 2.02; 95% CI: 1.39-2.94). Women, compared with men, were more likely to use herbs (OR: 2.42; 95% CI: 1.41-4.14); yoga, tai chi, or pilates (OR: 2.09; 95% CI: 1.04-4.19); acupuncture, acupressure, or massage (OR: 2.45; 95% CI: 1.28-4.67); and spiritual activities (OR: 1.68; 95% CI: 1.09-2.60). The interactive effects of race and gender were significant in the use of herbs (P = 0.008); yoga, tai chi, or pilates (P = 0.011); acupuncture, acupressure or massage (P = 0.038); and spiritual activities (P < 0.001). CONCLUSION: There are race and gender differences in the use of various CAMs for OA. As benefits and limitations of CAM therapies vary, clinicians must be aware of these differences.

Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care.

Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.

Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis.

OBJECTIVE: While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA. METHODS: A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS: In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02). CONCLUSION: Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.

Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging.

Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity.

OBJECTIVE: Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS: We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS: The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS: Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Widespread Pain Is Associated with Increased Risk of No Clinical Improvement After TKA in Women.

BACKGROUND: When conservative treatments do not work, TKA may be the best option for patients with knee osteoarthritis, although a relatively large proportion of individuals do not have clinically important improvement after TKA. Evidence also suggests that women are less likely to benefit from TKA than men, but the reasons are unclear. Widespread pain disproportionately affects women and has been associated with worse outcomes after joint arthroplasty, yet it is unknown if the effect of widespread pain on TKA outcomes differs by patient gender. QUESTIONS/PURPOSES: (1) Does the association between widespread pain and no clinically important improvement in osteoarthritis-related pain and disability 2 years after TKA differ between men and women? (2) Does the use of pain medications 2 years after TKA differ between those with widespread pain and those without widespread pain before surgery? METHODS: Osteoarthritis Initiative (https://nda.nih.gov/oai/) study participants were followed annually from March 2005 until October 2015. Participants who underwent TKA up to the 7-year follow-up visit with pain/disability assessment at the protocol-planned visit before TKA and at the second planned annual visit after surgery were included in the analysis. Among 4796 study participants, 391 had a confirmed TKA, including 315 with pain/disability assessment at the protocol-planned visit before TKA. Overall, 95% of participants (298) had the required follow-up assessment; 5% (17) did not have follow-up data. Widespread pain was defined based on the modified American College of Rheumatology criteria. Symptoms were assessed using the WOMAC pain (range 0 to 20; higher score, more pain) and disability (range 0 to 68; higher score, more disability) scores, and the Knee Injury and Osteoarthritis Outcome Score for pain (range 0 to 100; higher score, less pain). Improvements in pain and disability were classified based on improvement from established clinically important differences (decrease in WOMAC pain ≥ 1.5; decrease in WOMAC disability ≥ 6.0; increase in Knee Injury and Osteoarthritis Outcome Score for pain ≥ 9). At baseline, more women presented with widespread pain than men (45% [84 of 184] versus 32% [36 of 114]). Probability and the relative risk (RR) of no clinically important improvement were estimated using a logistic regression analysis in which participants with widespread pain and those without were compared. The analyses were done for men and women separately, then adjusted for depression and baseline outcome scores. RESULTS: Among women, preoperative widespread pain was associated with an increased risk of no clinically important improvement 2 years after TKA, based on WOMAC pain scores (13.5% versus 4.6%; RR 2.93 [95% CI 1.18 to 7.30]; p = 0.02) and the Knee Injury and Osteoarthritis Outcome Score for pain (16.5% versus 4.9%; RR 3.39 [95% CI 1.34 to 8.59]; p = 0.02). Given the lower and upper limits of the confidence intervals, our data are compatible with a broad range of disparate associations between widespread pain and lack of clinically important improvement in WOMAC pain scores (RR 0.77 [95% CI 0.22 to 2.70]; p = 0.68) and the Knee Injury and Osteoarthritis Outcome Score for pain (RR 1.37 [95% CI 0.47 to 4.00]; p = 0.57) among men, as well as clinically important improvement in WOMAC disability scores among men (RR 0.72 [95% CI 0.20 to 2.55]; p = 0.61) and women (RR 1.98 [95% CI 0.92 to 4.26]; p = 0.08). Participants presenting with widespread pain before TKA were more likely than those without widespread pain to use medication for symptoms of knee osteoarthritis most days for at least 1 month 2 years after TKA (51% [61 of 120] versus 32% [57 of 178]; mean difference, 18.8 [95% CI 7.3 to 30.1]; p < 0.01). CONCLUSIONS: Widespread pain before TKA was associated with an increased risk of no clinically important improvement in knee pain 2 years postoperatively among women. Because of the small number of men with widespread pain in the sample, the results for men were inconclusive. In clinical practice, screening TKA candidates for widespread pain may be useful, and expectations of surgical outcomes may need to be tempered if patients have a concurrent diagnosis of widespread pain. Future studies should include more men with widespread pain and investigate if treatment of widespread pain before or concurrent with TKA surgery may improve surgical outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Nonsteroidal Anti-Inflammatory Drug Use in Chronic Arthritis Pain: Variations by Ethnicity.

PURPOSE: Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors. METHODS: Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method. RESULTS: Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P <0.001), less likely to have private medical insurance (P <0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]). CONCLUSIONS: Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.

Modifiable Determinants of Exercise Use in a Diverse Ethnic Population With Osteoarthritis.

OBJECTIVE: To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA). METHODS: Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method. RESULTS: Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]). CONCLUSION: Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.

Effect of a Positive Psychological Intervention on Pain and Functional Difficulty Among Adults With Osteoarthritis: A Randomized Clinical Trial.

Importance: Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. Objective: To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. Design, Setting, and Participants: The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017. Interventions: The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists. Main Outcomes and Measures: The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction. Results: The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P < .001; functional difficulty: χ23 = 22.11, P < .001), differences were small and did not vary by treatment group or race. Exploratory analyses suggested that the intervention had counterintuitive effects on secondary outcomes. Conclusions and Relevance: The results of this randomized clinical trial do not support the use of positive psychological interventions as a stand-alone treatment for pain among white or African American veterans with knee osteoarthritis. Adaptations are needed to identify intervention components that resonate with this population, and the additive effect of incorporating positive psychological interventions into more comprehensive pain treatment regimens should be considered. Trial Registration: ClinicalTrials.gov Identifier: NCT02223858.

Epidemiology of osteoarthritis: literature update.

PURPOSE OF REVIEW: The purpose of this review is to highlight recent studies of osteoarthritis epidemiology, including research on prevalence, disease impact, and potential risk factors. RECENT FINDINGS: Osteoarthritis is highly prevalent in the United States and around the globe. It is a leading cause of disability and can negatively impact people's physical and mental well being. Healthcare resources and costs associated with managing the disease can be substantial. There is increasing evidence that there are different osteoarthritis phenotypes that reflect different mechanisms of the disease. Various person-level risk factors are recognized, including sociodemographic characteristics (e.g. female sex, African-American race), genetic predispositions, obesity, diet-related factors, and high bone density/mass. Joint-level risk factors include specific bone/joint shapes, thigh flexor muscle weakness, joint malalignment, participation in certain occupational/sports activities, and joint injury. Recent studies have enhanced our understanding of preradiographic lesions associated with osteoarthritis. SUMMARY: Application of these new findings may allow us to develop innovative strategies and novel therapies with the purpose of preventing new disease onset and minimizing disease progression.

Race, sex, and risk factors in radiographic worsening of knee osteoarthritis.

OBJECTIVES: Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over 4 years and evaluate the role of established risk factors in observed race/sex differences. METHODS: Whites (WHs) (694 males and 929 females) and African-Americans (AAs) (92 males and 167 females) at risk for radiographic KOA were eligible. Cox shared frailty models were used to estimate race and sex group differences in radiographic worsening, defined by Kellgren-Lawrence (K-L) and OARSI joint space narrowing (JSN). Mixed effect models for repeated measures were used to estimate race- and sex-specific mean medial and lateral fixed joint space width (fJSW) over 4 years of follow-up, as well as annual loss of fJSW. RESULTS: Risk of OARSI medial JSN grade worsening was higher among AA males than WH females [HR = 2.28, (95% CI: 1.14-4.57)], though adjustment for KOA risk factors attenuated the association. Compared to WH females, WH males had lower risk of K-L grade worsening [adjusted HR = 0.75 (95% CI: 0.58-0.96)]. Mean baseline medial fJSW (mm) was 6.49 in WH and AA males, 5.42 in WH females, and 5.41 in AA females. Annual change in mean medial fJSW was greater in AA males (-0.19mm/year) than in other subgroups (-0.09 WH males, -0.07 WH females, -0.10 AA females, p < 0.0001). Compared to WHs, AAs had less lateral fJSW at baseline and throughout follow-up. CONCLUSIONS: Compared to WHs and AA females, AA males experienced higher risk of medial joint space loss. Controlling for established risk factors attenuated associations between race/sex and disease worsening, suggesting that risk factors such as obesity, history of knee injury, and bony finger joint enlargements largely explain race/sex variations in rates of KOA development and progression.

Race and Rehabilitation Destination After Elective Total Hip Arthroplasty: Analysis of a Large Regional Data Set.

BACKGROUND: Three-quarters of patients who undergo total hip replacement (THR) receive postsurgical rehabilitation care in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or through a home health agency. The objectives of this study are to examine racial differences where THR recipients receive postsurgical rehabilitation care and determine whether discharge destination is associated with hospital readmission. METHODS: Using the Pennsylvania Health Care Cost Containment Council database, we selected African American (AA) or white adults who underwent THR surgery (n = 68,016). We used multinomial logistic regression models to assess the relationship between race and postsurgical discharge destination. We calculated 90-day hospital readmission as function of discharge destination. RESULTS: Among patients <65 years, compared to whites, AAs had a higher risk of discharge to an IRF (adjusted relative risk ratio [aRRR]: 2.56, 95% confidence interval [CI]: 1.77-3.71) and a SNF (aRRR 3.37, 95% CI: 2.07-5.49). Among those ≥65 years, AA patients also had a higher risk of discharge to an IRF (aRRR: 1.96, 95% CI: 1.39-2.76) and a SNF (aRRR: 3.66, 95% CI: 2.29-5.84). Discharge to either IRF or SNF, instead of home with self-care, was significantly associated with higher odds of 90-day hospital readmission (<65 years: adjusted odds ratio [aOR]: 4.06, 95% CI: 3.49-4.74; aOR: 2.05, 95% CI: 1.70-2.46, respectively; ≥65 years: aOR: 4.32, 95% CI: 3.67-5.09, respectively; aOR: 1.74, 95% CI: 1.46-2.07, respectively). CONCLUSIONS: Compared to whites, AAs who underwent THR were more likely to be discharged to an IRF or SNF. Discharge to either facility was associated with a higher risk of hospital readmission.

Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Health Care Access Matters.

OBJECTIVE: To determine if severity of osteoarthritis-related knee pain is associated with a willingness to undergo total knee replacement (TKR) and whether this association is confounded or modified by components of socioeconomic status and health care coverage. METHODS: Cross-sectional analysis was conducted among 3,530 Osteoarthritis Initiative study participants. Logistic regression models were used to assess the effect of knee pain severity (where 0 = none, 1-3 = mild, 4-7 = moderate, and 8-10 = severe) on willingness to undergo TKR. Stratified analyses were conducted to evaluate whether socioeconomic status and health care coverage modify the effect of knee pain severity on willingness. RESULTS: Participants with severe knee pain, compared to participants without pain, were less willing to undergo TKR (odds ratio [OR] 0.73, 95% confidence interval [95% CI] 0.57-0.93). This association was attenuated when adjusted for age, sex, comorbidity, depression, health insurance coverage, prescription medicine coverage, health care source, education, income, employment, race, and marital status (adjusted OR 0.92, 95% CI 0.68-1.24). The odds of willingness to undergo TKR were significantly lower in those with the highest level of pain, compared to those without pain, among participants without health insurance (adjusted OR 0.08, 95% CI 0.01-0.56), but not among those with health insurance (adjusted OR 1.03, 95% CI 0.73-1.38), when adjusted for demographic, clinical, health care access, and socioeconomic factors (P = 0.015). However, <5% of participants were without health insurance. CONCLUSION: Among participants without health insurance, severe knee pain was paradoxically associated with less willingness to undergo TKR. Policies that improve access to quality health care may affect patient preferences and increase utilization of TKR surgery among vulnerable populations.

Patient preferences for total knee replacement surgery: Relationship to clinical outcomes and stability of patient preferences over 2 years.

OBJECTIVE: Evaluate the relationship between patient preferences for total knee replacement (TKR) with receipt of TKR, and assess participant characteristics that may influence change in willingness to undergo TKR. METHODS: Structured interviews of knee osteoarthritis (OA) patients were conducted. Logistic regression models were conducted to assess the association between baseline willingness and eventual receipt of TKR, adjusted for sociodemographic and clinical variables. Mixed models for repeated measures were used to estimate the effects of sex, race, social support, Δ WOMAC, and orthopedic consult on change in willingness. RESULTS: A total of 589 participants were willing, and 215 participants were unwilling to undergo TKR. Willing participants, compared to others, were more often White (69.4% vs. 48.4%), with more than a high school education (60.8% vs. 47.0%) and employed (39.1% vs. 26.5%). At follow-up, the odds of having TKR were twice as high among those who were willing to have the procedure at baseline, but this was no longer significant when adjusted for demographic variables (adjusted OR = 1.82, 95% CI: 0.89-3.69). Willingness to undergo TKR declined over 2 years. Among those who were willing to undergo TKR at baseline but did not obtain one, only 66.5% were still willing at the 2-year follow-up. This decline was less among those who had a greater increase (>median) in WOMAC disability (adjusted Δ = -0.34, 95% CI: -0.47 to -0.20) than those who had minimal change in their WOMAC disability (p = 0.08). The decline in willingness was also less among those who had seen an orthopedic surgeon (adjusted Δ = -0.32, 95% CI: -0.46 to -0.17) than those who did not (p = 0.05). CONCLUSIONS: Preference for TKR was consistent with TKR surgery utilization, but not after controlling for patient demographic characteristics. Willingness to undergo TKR declined over time, but this decrease was mitigated by worsening OA-related disability and by consultation with an orthopedic surgeon.

Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial.

BACKGROUND: A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA. QUESTIONS/PURPOSES: We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA? METHODS: Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report. RESULTS: The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679). CONCLUSION: A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future. LEVEL OF EVIDENCE: Level I, therapeutic study.

Improvement following total knee replacement surgery: Exploring preoperative symptoms and change in preoperative symptoms.

OBJECTIVE: To determine whether changes in preoperative osteoarthritis (OA) symptoms are associated with improvement after total knee replacement (TKR) and to identify predictors of clinically significant improvement. METHODS: Data on Osteoarthritis Initiative participants who were annually assessed and underwent TKR were included. T0 was the assessment prior to TKR while T-1 was the assessment prior to that. T+2 was the second assessment after TKR. We compiled data on the Western Ontario and McMaster Universities OA Index (WOMAC), OA-related symptoms, and radiographic severity. We defined clinically significant improvement as improvement in WOMAC total score ≥ to the minimal important difference (MID) (0.5 SD of mean change) between T0 and T+2 and also considered other definitions of improvement. Logistic regression models were performed to evaluate the relationship between improvement and preoperative measures. RESULTS: Improved (n = 211) compared to unimproved (n = 58) patients had greater worsening of their WOMAC pain (p = 0.002) and disability (p < 0.001) from T-1 to T0. Preoperative measures as predictors of improvement included higher WOMAC disability (OR = 1.08, p < 0.001), presence of chronic OA symptoms in the surgical knee (OR = 5.77, p = 0.033), absence of OA-related symptoms in the contralateral knee (OR = 9.25, p < 0.001), exposure to frequent knee bending (OR = 3.46, p = 0.040), and having a Kellgren-Lawrence x-ray grade of ≥2 in the contralateral knee (OR = 4.71, p = 0.010). CONCLUSIONS: More than 75% of participants had improvement after TKR. Improved patients were more likely to have escalation of OA pain and disability prior to surgery than unimproved patients. Other preoperative measures predicted improvement after TKR.

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.