Published online May 18, 2020. doi: 10.5312/wjo.v11.i5.265
Peer-review started: January 1, 2020
First decision: February 19, 2020
Revised: April 1, 2020
Accepted: April 8, 2020
Article in press: April 8, 2020
Published online: May 18, 2020
Processing time: 138 Days and 9.1 Hours
Total joint arthroplasty is one of the most common surgeries performed in the United States with total knee arthroplasty being one of the most successful surgeries for restoring function and diminishing pain. Even with the demonstrated success of total knee arthroplasty and a higher prevalence of arthritis and arthritis related disability among minorities, many studies have shown that pre-operative expectations regarding pain relief after total joint replacement differ by gender and race, affecting post-operative outcomes. Racial and gender disparity remains a constant issue in providing appropriate care for the adult reconstruction patient.
The purpose and motivation behind this non-interventional study is to measure pre-operative patient expectations and correlate them with post-operative expectations, satisfaction and clinical outcomes after total joint replacement as it relates to race and gender. Clinical research examining patient expectations will increase awareness in the orthopaedic community to address the challenge of musculoskeletal health disparities and stimulate future research and focused strategies on how to manage patient’s surgical expectations and improve patient outcomes across racial and ethnic groups.
Our main objective was to determine and explore potential factors connected to differences in utilization and outcomes of total knee arthroplasties (TKA) associated with race and gender, and to determine the role of patient expectations. Our study looked into characteristics such as, social support, pain catastrophizing, and depression in patients’ lives that may have led to these results and may offer additional understanding into race and gender disparities within TKA.
One hundred and thirty-three patients undergoing primary TKA were enrolled into this study from 2013 through 2015. Demographic characteristics, such as age, gender, marital status, race, and ethnicity, were collected. Patients in the study were asked to complete questionnaires either via email, telephone, or at their pre- and post-operative office visits. The questionnaires were completed at different study points. Study point 1: prior to their operation, Study point 2: 4 to 8 wk, Study point 3: 9 to 14 mo post-operatively. The validated patient reported outcome measure (PROM) questionnaires included: (1) HSS patient expectation questionnaire; (2) Social support survey; (3) Pain catastrophizing survey; (4) Visual analogue pain scale; (5) Geriatric depression scale; (6) Knee Injury and Osteoarthritis Outcome Scores (KOOS) (Knee)- routinely collected as part of standard care at this time; and (7) E-5D- routinely collected as part of standard of care at this time.
In our findings, females were associated with worse preoperative KOOS for symptoms, pain, and activities of daily living. African Americans were associated with worse KOOS for pain, activities of daily living, and quality of life. Despite worse preoperative scores, no difference was noted in these categories between the groups postoperatively. Additionally, Pain Catastrophizing Scale, was significantly different for all subscales and total score within Age Group (P < 0.05), and the Magnification, Helplessness subscales as well as the Total score were significantly different between groups for Race and Relationship Status (P < 0.01). Our results indicate that women and black patients undergoing TKA presented with worse preoperative KOOS scores compared with white patients. However, outcomes were good among all groups postoperatively, and neither race nor gender was associated with compromised post-operative outcomes in relation to pain, ADLs or QOL. Due to this, the question still remains, why is TKA underutilized within these groups and what can we do to aid in fixing the disparities.
Our study concluded that there are multiple variations in pre-operative demographic variables, psychometric scale, pain catastrophizing scale and expectation vs outcomes. We noticed that while female and African American patients have lower preoperative KOOS scores compared to white male patients, their outcomes are not affected. Irrespective of these findings and due to lack of postoperative differences in outcomes between these groups, TKA is a valid option for minorities and should be offered at the same rate as their white counterparts. These findings may be valuable in counseling patients and surgeons regarding the value of increased utilization of TKA for African Americans and women. Further study is necessary to better understand the lower utilization or later presentation observed in these populations.
It is necessary to continue research on the disparities found in TKA within African American communities and women. While our study explores certain factors like social support, depression, pain catastrophizing, and bias, there is more to be considered before any determinations can be concluded. What we do know, however, regardless of the factors, we as physicians have a responsibility to tackle these disparities in hopes of providing equal and quality care to all races and genders.