Walid F. Gellad, MD, MPH

Melinda Maggard Gibbons, MD, MSHS

Paul G. Shekelle Shekelle, MD, PhD

Center for the Study of Healthcare Provider Behavior
Background

• Osteoarthritis is a leading cause of disability • Ttl o a Jit o n Rl t ep acement (TJR) is the most eff 

e

surgical option for moderate to severe osteo

• Substantial evidence that disparities exist in T

utilization utilization in non‐VA settings settings

• Reasons behind these disparities are comple

fully known

Center for the Study of Healthcare Provider Behavior 
Purpose

• To compare Total Joint Replacement (T

surg y er in VA settings with Non‐VA se

First Generation:

Second Generation:

Studies examining the Thir

First Generation:

Studies

documenting the

existence and the

magnitude of the

Studies examining the

reasons for observed

disparities. Reasons can

be classified as a) patient‐

level factors b) provider

Stud

int

a

magnitude of the

disparities.

level factors, b) provider‐

level factors, and c)

system‐level factors.

Center for the Study of Healthcare Provider Behavior 
Key Question #1

• What is the evidence about the existe

magnitude of disparities in joint replasurgery in VA? How does this compare published published studies studies from non‐VA US

populations?

Center for the Study of Healthcare Provider Behavior 
Key Question #2

• What is the evidence about the patien

provider level, and system level factorcontribute to disparities in joint replacsurgery surgery in VA? How does this compare compare 

published studies from non‐VA popula

Center for the Study of Healthcare Provider Behavior 
Key Question #3

• What is the evidence regarding VA or 

interventions to reduce disparities in j

replacement surgery?

Center for the Study of Healthcare Provider Behavior 
Topic Development & Sea

• PubMed search from 1966 through 2011 us

standard search terms

• Data about study characteristics, characteristics, patient patient

characteristics, and outcomes were extract

experienced reviewers

Center for the Study of Healthcare Provider Behavior 
Methods: Study Selectio

• Two reviewers assessed for relevance t

abstracts of citations identified from litsearches

• We limited search inclusion criteria:

– Peer reviewed articles involving human su– Articles published in the English lang g ua e– Medline only

• Included Included articles articles were screened screened using a

standardized screening form for data ab

Center for the Study of Healthcare Provider Behavior 
Methods: Data Synthes

• Studies analyzed to compare characte

methods, and findings

• Summary of findings for each questio

on qualitative synthesis

Center for the Study of Healthcare Provider Behavior 
Methods: Peer Review

• Draft version of report was reviewed b

– Several technical experts– VA clinical leadership

• R i ev ewer comments were add d resse a

responses incorporated in the final re

Center for the Study of Healthcare Provider Behavior 
144 Articles assessed

Results: Flow Diagram of Article

299 Articles Identified

144 Articles assessed

for eligibility 70 Reject

24 No jo

dis

74 Articles Assessed

dis

19 Inappro

(includin

2

3 T

155 Rejected, Title screen 3 T

2 

KQ2=37 (Racial Only)

3 Compare VA v. Non‐VA

14 VA

KQ1=25

2 VA Racial

1 VA Gender**

K

1 V

14 VA

20 Non‐VA

1 VA Gender**

22 Non‐VA Racial

*Key question categories were not mutually exclusive, meaning some of the 22 “KQ1” studies we35 “KQ2” category.** The 28 articles addressing gender disparities in non-VA populations were not included in the ta

Center for the Study of Healthcare Provider Behavior 
Results

Key Question #1: VA

• Data supporting existence of disparities in r

joint replacement surg y er in VA are not ver

– Two studies of racial disparities (only one 

national), one study of gender

• The magnitude of the disparities in VA as

documented in these studies is about the s

magnitude based on more extensive data f

VA p po ulations (about 1.5‐3 fold)

Center for the Study of Healthcare Provider Behavior 
Results

Key Question #1: Non‐V

• Racial disparity literature in TJR outside the 

robust than within the VA

• Studies of non‐VA US populations consisten

that:

– Black patients receive fewer TKR (Total K

Rep ace e t) lacement) ope at o s rations t ah n whites

– Men receive fewer TKR operations than 

• Studies Studies assessing assessing differences differences in utili ation z b

clinical appropriateness or need are fewer i

Center for the Study of Healthcare Provider Behavior 
Key Question #1: Summa

& Quality of Evidence

• There are few studies that examine whethe

differences in TKR rates represent true disp

based in clinical need

• Scant data on racial disparities in total hip

replacement

• Evide ce n in non‐VA is robust a dn e de ce vidence 

is not

Center for the Study of Healthcare Provider Behavior 
Key Question #2

• The conceptual framework of Kilbourn

colleagues was used to organize the a

reasons for disparities

Center for the Study of Healthcare Provider Behavior
Health Care System Factors

Heal ht services organi i zat on,

financing, and delivery

Health care organizational

l l

Patient Factors

culture, quality improvement

Provider F

Beliefs and preferences

Race/ethnicity, culture,

familial context

Provider F

Knowledg

attitud

familial context

Education and resources

Biology Clinical Encounter

Compe

deman

Bias gy

Provider

communication

Cultural competence

Center for the Study of Healthcare Provider Behavior 

Kilbourne, A. M., et al., Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health, 2006. 96(12): p. 2113-21.
Results

Key Question #2: Direct Compa

• Studies that directly compared VA and 

County h il osp tal patients f d oun no diff

in clinical appropriateness of TJR betw

patients at a County hospital and pati

nea by r VA

Center for the Study of Healthcare Provider Behavior 
Results

Key Question #2: VA Dat

• Evidence about patient‐, provider‐, and syst

factors that contribute to disparities in joint

replacement surgery in the VA comes from 

small studies recruiting patients from one o

medical centers

Center for the Study of Healthcare Provider Behavior 
Results

Key Question #2: VA Dat

• In general, compared with whites, black patients have:

– Lower expectations about the effectiveness of joint 

– Less f ili it familiarity with the procedure

– More likely to view prayer and other techniques as 

managing arthritis pain

• Blacks may be less likely to be referred to specialists fo

replacement or to have TJR recommended by a special

– Some of these differences may be explained by pat

preferences

• One study examining communication between patients 

orthopedic surgeons in the VA found little difference by 

Center for the Study of Healthcare Provider Behavior 
Results

Key Q i uest on #2: Non‐VA D

• Evidence in non‐VA settings suggests that m

patients (African American most studied) m

– Less knowledge about joint replacement surger– Perceive fewer health benefits

– Greater fear about the surgery

– Less likely to be referred to a surgeon– Less likely to consider surg y er

• Minority patients are less likely to be treate

volume centers centers or by high volume provider

provider

a system‐level factor that has not been stud

within VA

Center for the Study of Healthcare Provider Behavior

VA
Results

Key Question #2: Summary a

Q li ua ty of Evidence

• Scant data on reasons for disparities f

races (Hispanic, Asian)

• Alth h oug the i di id l individual st di u es are of 

quality, the overall quality of evidence 

conclusions is low because the studie

small and limited to a few sites

Center for the Study of Healthcare Provider Behavior 
Results

Key Question #3

• We identified identified only one study of an interven

interven

designed to reduce joint disparities in VA

• Th t a st du y t td es e an i t ti n ervention di d es gned 

improve expectations and examined only to

repl t acement

• Other potential causes of disparities have n

the subjects of interventions, and no study 

assessed changes in the actual delivery of j

replacement surgery

Center for the Study of Healthcare Provider Behavior 
Limitations

• Publication bias• Study quality• The age of data

• Generalizability

• Types of disparities represented in the

literature

• Focus has been on smaller disparity st

to this point

Center for the Study of Healthcare Provider Behavior 
Future Recommendation

• More recent data on national rates of racial and ge

disparities in TJR (both knee and hip) are needed

• Need to measure disparities in the context of clinic

• With the increasing number of women and Hispan

planning now to better understand barriers for rec

treatment as well as the potential need for TJR in t

warranted

• Based on the results results, VA should test more interven

interven

diminish disparities, addressing the need for third 

work, and implement implement those found effective effective nation

nation

Center for the Study of Healthcare Provider Behavior 
Synthesis Team

• Paul G. Shekelle, MD, PhD

• Walid F. Gellad, MD, MPH

• Melinda Maggard Gibbons, MD, MSHS

• Mary E. Vaiana, PhD

• Isomi M. Miake‐Lye, BA• Jessica M. Beroes, BS

Center for the Study of Healthcare Provider Behavior 
Thank you

• VA Greater Los Angeles

– Evidence Synthesis Program & Southern

California/RAND Evidence‐based Practice C

– Center for Surgical Surgical Outcomes Outcomes and Quality Quality

• VA Pittsburgh Center for Health Equity Resear

Promotion

• VA Health Services Research &Development S

Center for the Study of Healthcare Provider Behavior