Evidence-based Synthesis Program 

A Comparison of Joint Replacement 

Disparities in VA and Non-VA 

Settings: A Systematic Review

Department of Veterans Affairs

Health Services Research & Development Service

September 2011

Investigators:

Principal Investigators: 

Walid F. Gellad, MD, MPH

Melinda Maggard Gibbons, MD, 

MSHS

Research Associates:

Isomi M. Miake-Lye, BA

Medical Editor:

Mary E. Vaiana, PhD

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

West Los Angeles VA Medical Center

Los Angeles, CA

Paul G. Shekelle, MD, PhD, Director
ii

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. 

The ESP Centers generate evidence syntheses on important clinical practice topics, and these 

reports help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Gellad WF, Maggard MA, Miake-Lye IM, Shekelle PG. A Comparison 

of Joint Replacement Disparities in VA and Non-VA Settings: A Systematic Review. VA-ESP 

Project #05-226; 2011

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA 

funded by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that conflict with material presented 

in the report.
iii

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Abbreviations Table....................................................................................................................................... 4

INTRODUCTION

Background.................................................................................................................................................... 5

METHODS

Topic Development........................................................................................................................................ 6

Search Strategy.............................................................................................................................................. 6

Study Selection.............................................................................................................................................. 6

Data Abstraction ............................................................................................................................................ 7

Quality Assessment ....................................................................................................................................... 7

Data Synthesis............................................................................................................................................... 7

Rating the Body of Evidence......................................................................................................................... 8

Peer Review................................................................................................................................................... 8

RESULTS

Literature Flow .............................................................................................................................................. 9

Description of Evidence .............................................................................................................................. 10

Key Question #1. What is the evidence about the existence and magnitude of disparities 

in joint replacement surgery in VA? How does this compare to published studies from non-VA 

US populations?........................................................................................................................................... 10

Key Question #2. What is the evidence about the patient level, provider level, and system level 

factors that contribute to disparities in joint replacement surgery in VA? How does this compare 

to published studies from non-VA populations?.......................................................................................... 15

Key Question #3. What is the evidence regarding VA or non-VA interventions to reduce disparities 

in joint replacement surgery? ...................................................................................................................... 22

SUMMARY AND DISCUSSION

Summary of Evidence by Key Question ..................................................................................................... 24

Limitations................................................................................................................................................... 26

Recommendations for Future Research....................................................................................................... 26

REFERENCES ................................................................................................................................................... 28

APPENDIX A. Search Strategy................................................................................................................. 34
iv

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

APPENDIX B. Study Selection Form..................................................................................................... 35

APPENDIX C. Data Extraction Form .................................................................................................... 36

APPENDIX D. Newcastle Ottawa Scale Criteria Used in Quality Assessment.................. 38

APPENDIX E. Peer Review Comments/Author Responses ............................................................ 39

APPENDIX F. Evidence Tables................................................................................................................... 43

TABLES

Table 1. Abbreviations................................................................................................................................... 4

Table 2. Cohort description ......................................................................................................................... 10

Table 3. Baseline and post-intervention total knee replacement expectations (n=64). Western Ontario 

and McMaster Universities Osteoarthritis Index (WOMAC) scale 0-100, where higher scores 

reflect poorer expectations........................................................................................................................... 23

FIGURES

Figure 1. Conceptual Framework.................................................................................................................. 5

Figure 2. Kilbourne et al. model: Understanding the origins of health and health care disparities 

from a health services research perspective: key potential determinants of health disparities 

within the health care system, including individual, provider, and health care system factors..................... 7

Figure 3. Literature Flow............................................................................................................................... 9
5

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

EVIDENCE REPORT

INTRODUCTION

BACKGROUND

The leading cause of disability in the United States is osteoarthritis.1, 2 There is no known cure. 

Consequently, osteoarthritis is managed with a variety of treatments to reduce disability, improve 

function, and alleviate symptoms. The most effective surgical option for moderate to severe 

osteoarthritis in the knee or hip is total joint replacement (TJR).3, 4 TJR is often considered 

appropriate in cases where other non-surgical treatments have not brought adequate relief.2, 5-7

Although TJR is highly successful at treating advanced hip or knee osteoarthritis, there is a 

large body of evidence suggesting that disparities exist in TJR utilization in non-VA settings.8-19

Although subgroups of patients may utilize services differently depending on clinical needs, 

Kane et al. explain that “disparity in healthcare implies unequality, unlikeness, or unfair 

disproportion,”20 as opposed to extensive accepted variation in practice.21, 22 Measuring disparities 

usually means comparing rates of utilization of care, since measuring access to care directly can 

be difficult.20 But if only utilization is measured, and need for care is not taken into account, 

disparities might not be fully characterized. “Need for care” data are not easily captured, making 

this concept almost as hard to measure as access to care. Utilization data are so often relied upon 

when discussing disparities because of this difficulty of measuring access to care or need for 

care. 

In order to remedy disparities, they must first be documented and their causes better understood. 

Disparities in TJR utilizations have been well documented outside VA. The purpose of this 

report is to compare what is known about disparities in TJR in non-VA settings to disparities in 

TJR in the VA context.

Our conceptual framework identifies three “generations” of studies of disparities, based on 

whether the studies are documenting disparities, examining their underlying reasons, or assessing 

interventions to address them (see Figure 1). 

Figure 1. Conceptual Framework

Third Generation:

Studies examining 

interventions to address 

the observed disparities.

First Generation:

Studies documenting 

the existence and 

the magnitude of the 

disparities.

Second Generation:

Studies examining the 

reasons for observed 

disparities. Reasons 

can be classified as a) 

patient-level factors, b) 

provider-level factors, and 

c) system-level factors.
6

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

METHODS

TOPIC DEVELOPMENT

This project was nominated by Tamara L. Martin, MD and the Center for Health Equity Research 

and Promotion, with input from a technical expert group that included Said Ibrahim and David 

Atkins.

The final key questions are:

Key Question #1. What is the evidence about the existence and magnitude of disparities in 

joint replacement surgery in VA? How does this compare to published studies from non-VA US 

populations?

Key Question #2: What is the evidence about the patient level, provider level, and system level 

factors that contribute to disparities in joint replacement surgery in VA? How does this compare 

to published studies from non-VA populations?

Key Question #3: What is the evidence regarding VA or non-VA interventions to reduce 

disparities in joint replacement surgery?

Evidence Synthesis Program systematic reviews are done according to a standard protocol, 

which is modeled on the protocol used by the Evidence-Based Practice Center program. A 

detailed individual protocol is not created for each separate topic.

SEARCH STRATEGY

We searched PubMed for relevant literature from 1966 through July 2011, using standard search 

terms such as “disparities,” “variations,” “replacement,” and “arthroplasty” (see Appendix A 

for complete search strategy). We limited the search to peer-reviewed articles involving human 

subjects and published in the English language. We judged it unlikely for studies of US patients, 

either VA or non-VA, to be published in non-English language journals. Since our focus was 

US studies, we elected to forgo searching EMBASE. Also, since RCTs are not the study design 

to assess anything but third generation disparity questions, we elected to forgo searching the 

Cochrane Central Register of Controlled Trials (CENTRAL).

STUDY SELECTION

Two reviewers assessed for relevance the abstracts of citations identified from literature 

searches. Full text articles of potentially relevant abstracts were retrieved for further review. 

Each article was reviewed using a standard screener form (see Appendix B). Inclusion criteria 

were: 1) reported on hip, knee (or both) total joint replacement; 2) reported on patients treated 

within the VA or who were treated in non-VA health care settings in the United States; and 3) 

reported results of either racial/ethnic or gender disparities. There were no inclusion or exclusion 

criteria for study design. We excluded studies of joint replacement surgery for other sites (such 

as shoulder). Additionally, we excluded studies if there were about gender differences in the 

technical approach to the procedure (e.g., use of gender-specific prostheses).
7

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

DATA ABSTRACTION 

We abstracted the following data for each included study for the key questions: intervention(s), 

data source, study subjects, patient selection, years of data collection, study design, outcome 

measure(s), categorization of race(s), determination of race, assessment of receipt of procedure, 

assessment of disparity outcome, population sample size, mean/median patient age, response 

rate, subject follow-up, and covariates for result adjustment (Appendix C).

QUALITY ASSESSMENT

We assessed individual randomized studies using the criteria of Jadad.23 We assessed nonrandomized studies using items taken or derived from the Newcastle Ottawa Scale, involving 

representativeness of the sample and how key variables were assessed24 (see Appendix D for 

adapted variables).

DATA SYNTHESIS

We constructed evidence tables showing the study characteristics and results for all 

included studies, organized by key question. We critically analyzed studies to compare their 

characteristics, methods, and findings. We compiled a summary of findings for each key 

question or clinical topic, and drew conclusions based on qualitative synthesis of the findings. 

We used the conceptual framework of Kilbourne and colleagues (see Figure 2) to organize the 

reasons for disparities assessed in the second-generation studies.25 

Figure 2. Kilbourne et al. model:25 Understanding the origins of health and health care disparities 

from a health services research perspective: key potential determinants of health disparities within 

the health care system, including individual, provider, and health care system factors

Health Care System Factors

Health services organization, financing, and delivery

Health care organizational culture, quality improvement

Patient Factors

Beliefs and preferences

Race/ethnicity, culture, 

familial context

Education and resources

Biology

Clinical Encounter

Provider 

communication

Cultural competence

Provider Factors

Knowledge and 

attitudes

Competing demands

Bias
8

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

RATING THE BODY OF EVIDENCE

We assessed the overall quality of evidence for outcomes using a method developed by the 

GRADE Working Group, which classified the evidence across outcomes according to the 

following criteria:

• High = Further research is very unlikely to change our confidence about the estimate 

of effect.

• Moderate = Further research is likely to have an important impact on our confidence 

in the estimate of effect and may change the estimate.

• Low = Further research is very likely to have an important impact on our confidence 

in the estimate of effect and is likely to change the estimate.

• Very Low = Any estimate of effect is very uncertain.

The ESP SharePoint site {http://vaww.infoshare.va.gov/sites/hsrd/esp/default.aspx} contains 

reference articles that describe guidelines for the GRADE quality assessment system.

PEER REVIEW

A draft version of this report was reviewed by seven technical experts as well as by VA clinical 

leadership. Their comments and our responses are presented in Appendix E.
9

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

RESULTS

LITERATURE FLOW

Our literature search identified 284 titles and abstracts from the electronic search, and one 

additional article from reference mining, for a total of 285 references. We excluded 155 titles 

as being clearly irrelevant. We conducted an update search after peer review, which yielded 

12 new articles, with an additional two articles from reference mining, bringing the total up to 

299 references. We retrieved 144 full-text articles for further review and excluded another 70 

references for various reasons (see Figure 3). We identified a total of 74 references for inclusion 

in the current review. We grouped the studies by key question, type of disparity, and whether 

the patient population was of VA or non-VA origin. Figure 3 details the flow of articles from 

citations to the number of references informing each of the key questions. 

Figure 3. Literature Flow

70 Rejected, Screener level

24 No joint replacement or 

 disparity mentioned

19 Inappropriate study design 

 (including non-syst. review)

 22 Non US

 3 Technical focus

 2 Background

74 Articles Assessed*

Literature Search

(n=296)

299 Titles

Reference Mine

(n=3)

KQ3=1

 1 VA Racial

155 Rejected, Title screen

144 Articles Requested

KQ2=37 (Racial Only)

 3 Compare VA v. Non-VA

14 VA

20 Non-VA

KQ1=25

2 VA Racial

1 VA Gender**

22 Non-VA Racial

*Key question categories were not mutually exclusive, meaning some of the 22 “KQ1” studies were also part of the 35 “KQ2” 

category.

**The 28 articles addressing gender disparities in non-VA populations were not included in the tables or report.
10

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

DESCRIPTION OF EVIDENCE

Studies of racial disparities in joint replacement that focus on VA patients are clustered around 

7 patient cohorts (see Table 2). Two of these studies report on rates of receipt of total joint 

replacement (first generation studies26, 27); the remaining are second generation studies attempting 

to identify mechanisms underlying the known disparities. One study28 includes Hispanic 

ethnicity; otherwise the studies focus on disparities between blacks and whites.

Table 2. Cohort description

Author/year Study Cohort

Hausmann, 201026 Orthopedic Clinics Pittsburgh and Cleveland

Hausmann, 201129 Orthopedic Clinics Pittsburgh and Cleveland

Ang, 200930 VA+ County Hospital in Indiana

Ang, 200931 VA+ County Hospital in Indiana

Ang, 200832 VA+ County Hospital in Indiana

Jones, 200833 VA Philadelphia and Pittsburgh

Groeneveld, 200834 VA Philadelphia and Pittsburgh

Jones, 200527 National VA Patient Treatment Files

Borrero, 200635 National VA Patient Treatment Files

Ibrahim, 200528 VA National Surgical Quality Improvement Program (NSQIP)

Lopez, 200536 Cleveland VA Primary Care Clinics

Ang, 200337 Cleveland VA Primary Care Clinics

Ibrahim, 200338 Cleveland VA Primary Care Clinics

Ibrahim, 200239 Cleveland VA Primary Care Clinics

Ibrahim, 200240 Cleveland VA Primary Care Clinics

Ibrahim, 200241 Cleveland VA Primary Care Clinics

Ibrahim, 200242 Cleveland VA Primary Care Clinics

Ibrahim, 200143 Cleveland VA Primary Care Clinics

Weng 200744 VA Greater Los Angeles Ambulatory Care

In addition we identified 22 non-VA first generation studies, one of which was a systematic 

review.20 There were 21 non-VA second-generation studies. There was only one third-generation 

study, which was of VA patients. For gender disparities, we identified 29 non-VA studies and one 

VA (first-generation) study. Only the VA study is discussed in this report. The evidence tables 

present details of each included study (see Appendix F).

KEY QUESTION #1. What is the evidence about the existence and 

magnitude of disparities in joint replacement surgery in VA? How 

does this compare to published studies from non-VA US populations?

VA Data

Three first-generation studies report on disparities in receipt of total joint replacement in VA 

settings. Two studies used national data; one was based in two institutions. All three studies were 

judged to have population-based or otherwise representative patient samples. Race was identified 

using self-report in one study and administrative data in the other two. In all three studies, 
11

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

administrative or medical record data were used to determine if a procedure had been performed. 

In all three studies, response rate or adequacy of follow-up were not applicable (see Appendix F, 

evidence table 1). 

One study examines a local cohort of 457 veterans seen between 2005-2008;26 another uses 

national VA patient treatment files from 1999-2001 to report on rates of receipt of knee 

replacement (only) among 260,856 veterans.27 Hausmann et al.26 recruited patients immediately 

before and after their orthopedic surgery clinic visit at two large VA hospitals (Pittsburgh and 

Cleveland) between 2005 and 2008. The primary outcome was whether patients received a 

recommendation for TJR from the surgeon, as determined by electronic medical record review. 

The secondary outcome was receipt of TJR at the VA within 6 months of study enrollment. The 

odds of receiving a TJR recommendation were lower for blacks than for white patients of similar 

age and disease severity (OR 0.46, 95% CI 0.26-0.83). This difference, however, was no longer 

significant after adjusting for patient preference for TJR (measured using a single item question). 

The adjusted odds of actual receipt of TJR were lower for blacks than for whites, although the 

results did not reach statistical significance (OR 0.41, 95% CI 0.16-1.05). 

In the second first-generation study, Jones et al.27 examine 260,856 patients with osteoarthritis 

(based on ICD-9 code 715.x) from the national VA patient treatment files in 1999 with 2-year 

follow up to determine rates of TKR. In the final statistical model, adjusting for age, gender, and 

Charlson comorbidity (without adjustment for disease severity), black patients were less likely 

than whites to have received TKR (OR 0.72, 95% CI 0.65-0.80).

One of the three studies reporting on disparities in receipt of TJR in VA settings assessed gender 

disparities.45 Borrero and colleagues analyzed a national sample of 1,986,093 VA patients aged 50 

years or older (1,923,524 male, 44,569 female) in the VA National Patient Care Database during 

fiscal year 1999. In this cohort, 172 (0.4%) women and 5,198 (0.3%) men received TKR (P<.001), 

and 91 (0.2%) women and 2,618 (0.1%) men received THR (P=.001). The odds ratios for receipt of 

TJR was 1.4 for women compared to men, which demonstrated the statistically significantly higher 

rates of TKR and THR in women. However, after adjusting for the presence of OA, there was no 

longer any significant difference in odds of receipt of TJR. The authors noted that women have a 

higher prevalence of OA-related disability, and additionally adjusted for this in an OA subcohort of 

329,461 patients (319,924 male, 9,537 female), which consisted of patients with a diagnosis of OA 

using the ICD-9-CM code. Within this subcohort, there were no differences by gender: 153 (1.6%) 

women and 4,638 (1.5%) men had TKR, and 73 (0.8%) women and 2147 (0.7%) men had THR. 

The authors suggest that an important factor in understanding gender differences in TJR is the 

difference in OA prevalence between men and women.

Non-VA Data

The literature on racial disparities in total joint replacement outside the VA is more robust than 

within the VA. However, we found only one systematic review on the topic of disparities in 

total knee replacement (Kane et al.20). An additional review on the epidemiology of knee and hip 

arthroplasty was identified.19 Its focus was not on disparities, nevertheless data on differences in 

utilization by gender and race was reported.

In 2007, Kane et al.20 published the results of a systematic review examining disparities in 

total knee replacement performed by the Minnesota Evidence-Based Practice Center and 
12

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

commissioned by the Agency for Healthcare Research and Quality. The review was presented 

to experts at an NIH Consensus Conference on Total Knee Replacement in December 2003. In 

discussing the limitations of the literature, the authors mention that some of the studies address 

rates of procedure use without paying attention to the size of the population at risk (patients with 

severe symptomatic knee/hip OA who might have an indication for TJR); this limitation is worth 

noting as rates of use are presented below.

The authors limited their search to English language articles between 1995-2003 and excluded 

studies with less than 100 observations; of the 176 references that they identified, only 4 met the 

inclusion criteria. The authors added another 3 studies from reference mining, for a total of 7 

studies. The 7 studies primarily use Medicare national claims to examine rates of disparities, with 

the exception of two studies: one examined a community cohort of elderly patients with arthritis, 

and the other examined a cross-sectional survey of people age 55 or older in Ontario, Canada. 

Each of the studies finds the highest rates of TKR use in whites compared with nonwhites. Most 

of these studies examining gender disparities found that women were more likely to receive joint 

replacement than men; in one study,46 women were less likely to receive joint replacement after 

adjusting for presence and severity of arthritis. The results of the Kane and colleagues review 

indicate that there are racial/ethnic and gender disparities in the receipt of TKR in the United States. 

A recent systematic review by Singh19 focused on studies of the incidence and prevalence of knee 

and hip arthroplasty. Included in this review were data from six studies, three of them from the 

United States, all reporting differences in utilization rates by gender, ethnicity, or both.

Our search found nine overlapping references that will not be discussed further, as they were 

included in Kane or Singh.8, 11, 12, 16, 47-51 Although not discussed here, they still appear in the 

evidence tables (see Appendix F).

More recent studies document the continued existence of racial/ethnic disparities in TKR. Jha et 

al.52 describe rates of both TKR and THR among the Medicare fee for service population, this 

time comparing 1992 to 2001. In their analysis, they compare blacks vs. nonblack patients in 

Medicare and stratified the analysis by gender. In each analysis, women had higher age-adjusted 

rates of procedure use than men, and nonblacks had higher rates than blacks. In 2001, nonblack 

men had a rate of 5.05/1000 population for TKR, compared with 1.85 for black men. Among 

women, rates of TKR per 1000 population were 6.6 among nonblacks and 5.1 among blacks. 

In another analysis of Medicare (one of the few including Hispanic ethnicity) from 2000, Skinner 

et al.53 compare rates of TKR adjusted for age and income and find that, compared with white 

men, the odds ratio for receipt of TKR for black men was 0.36 (0.34,0.38), for Hispanic men 

0.67 (0.62-0.73), and for Asian men 0.28 (0.24,0.32). White women and Hispanic women were 

more likely and as likely, respectively, as white men to receive TKR.

Another study looked at Medigap coverage and found disparities in receipt of joint replacement 

based on whether patients lived in a high, standard or low minority area. Patients were defined 

as living in a high-minority area if 60% or more of the population in their zip code was in one of 

the nonwhite minority groups. Low minority area was defined as 15% or less of residents in one 

of the non-white minority groups. Patients living in high minority areas were 20% less likely to 

undergo a hip or knee replacement as those who resided in low minority areas.54
13

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

Four additional studies, using older data and non-Medicare data sources, also found significant 

disparities. In an analysis using the Nationwide Inpatient Sample from 1990-2000, Jain et al.55

examine the percentage of all TKRs performed on black patients vs. white patients; however, the 

overall rate of TKR among blacks and whites is not known, and 27% of race data was missing. 

They found that the percentage of all TKRs performed on black patients has increased from 

1990-1993 (4.2% black), to 1994-1998 (5.9% black), to 1998-2000 (6.5% black). 

Bang also used the Nationwide Inpatient Sample, but from 1996-2005, and found that non-white 

groups had lower odds of THA and TKA compared with whites.56 All racial minority groups 

were 23% to 64% less likely to undergo arthroplasties. Racial disparities were larger than income 

disparities, and racial disparities were not confined to elderly or to low-income.

Hanchate et al.57 describe rates of knee replacement in the Health and Retirement Survey (HRS) 

from 1994-2004. They find no racial/ethnic differences in rates of TKR among women after 

adjusting for economic factors, including insurance, income, assets, and age. However, they find 

that black men are significantly less likely than white women to receive a TKR (OR 0.56 (0.33-

0.95), although the difference is no longer statistically significant when the sample is limited to 

those with self-reported arthritis. There were no disparities comparing Hispanics and whites. 

Finally, an analysis using hospital discharge data from Connecticut from 1996-1998, Olson 

and Foland58 examined rates of TKR; the analysis did not account for rates of severe OA, or 

preferences or need for TKR. They found that the age adjusted rates per 100K discharges for 

TKR was highest for black women (115.8, 95% CI 103.9-127.7) and lowest for black men (44, 

34.9-68.9) and Hispanic men (16.9, 10.1-23.8) and women (47.5, 37.8-57.2). White women had 

rates of 84.9 (82.4-87.4) and white men 66.5 (63.9 -68.9).

The Kane review focused on total knee replacement. There are no systematic reviews specifically 

examining racial/ethnic disparities in total hip replacement (THR). Many of the studies 

examining hip replacement use data that are quite old. Jha et al.52 included hip replacement 

in their analyses of Medicare data and found that in 2001, nonblack men had a rate of THR 

of 2.60/1000 population compared with 1.08/1000 for blacks. Among women, rates per 1000 

population in THR were 3.33 for nonblacks and 1.86 for blacks. Using data from 1997-2001 

hospital discharge records from two states included in the HCUP, Basu and Mobley59 found no 

difference in the likelihood of THR between blacks, whites and Hispanics in either 1997 or 2000, 

after adjusting for income, urban/rural, distance from hospital, and social isolation. They did not 

adjust for severity of arthritis. 

Two older studies (from the 1980s) using hospital discharge records from Hawaii60 and 

California14 examined rates of THR; the studies did not include information about the need for 

the procedure. Oishi et al.60 found no differences in rates of THR among whites and Asians for 

those under age 50, but lower rates among Asians for those over age of 50. Giacomini14 found 

no statistically significant difference in THR rates after adjusting for insurance status, age and 

comorbidities between whites, Hispanics, and blacks; however, Asians had lower odds of THR 

(0.47, 0.29-0.77).

One study outside the VA examined disparities in joint replacement surgery, combining TKR 

and THR. Francis et al.61 reported rates of TKR/THR in 2005 Medicare data, comparing rural 
14

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

and urban beneficiaries. They found that nonwhites are less likely than whites in rural areas to 

receive joint replacement (OR 0.69, 0.66-0.71); the disparity is more pronounced in urban areas. 

African Americans had lower odds than whites for receipt of the procedures in rural areas (OR 

0.68, 0.65-0.71). There were no differences in adjusted rates of joint replacement for Hispanic 

vs. white in rural areas, but there were differences in urban areas (OR 0.62). 

Finally, in one of the few studies that examined rates of TKR/THR among those in need (based 

on difficulty walking, joint pain, stiffness, or swelling),62 African American patients in the Health 

and Retirement Study (HRS) from 1998-2004 were less likely to receive joint replacement than 

whites (OR 0.34 (0.17-0.66)). The higher rate of joint replacement in women compared to men 

was appropriate, based on their assessment of need.

Summary of Findings

Data supporting existence of disparities in joint replacement surgery in VA are not very robust 

because they come from just three studies, two of which focus on racial disparities and only 

one of which focuses on gender disparities The magnitude of the racial disparities in VA as 

documented in these studies is about the same as the magnitude based on more extensive data 

from non-VA US populations (about 1.5-3 fold). The quality of evidence for this conclusion is 

low, based on sparseness and age of data. Thus we expect further research, both into racial and 

gender disparities, to have an important impact on our estimate of the magnitude of disparities. 

The literature on racial disparities in total joint replacement outside the VA is more robust than 

within the VA. Studies of non-VA US populations consistently find that black patients receive 

fewer TKR operations than whites, and men receive fewer TKR operations than women. The 

quality of evidence for this conclusion is high; thus future research is unlikely to change our 

confidence about the estimate of effect. However, future research is still necessary to evaluate 

these disparities over time and assess whether they are increasing or decreasing.

There are fewer studies that examine whether differences in TKR rates represent true disparities 

based on clinical need. Those that have examined this issue conclude in general, but not 

consistently, that disparities in joint replacement between blacks and non-blacks persist after 

adjusting for clinical need. The quality of evidence for this conclusion is moderate. Further 

research is likely to affect our confidence in the estimate of disparities and may change the 

estimate.

Data about differences in utilization and disparities for total hip replacement in both non-VA 

US and VA populations are scant, and no conclusions can be drawn. The quality of evidence is 

therefore very low.

Data about differences in utilization for other races (Hispanic, Asian) are scant, and no 

conclusions can be drawn. The quality of evidence is therefore very low.
15

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

KEY QUESTION #2. What is the evidence about the patient level, 

provider level, and system level factors that contribute to disparities 

in joint replacement surgery in VA? How does this compare to 

published studies from non-VA populations?

Direct Comparison of VA and Non-VA Patients

Three studies include both VA and non-VA patients and examine racial disparities in joint 

replacement, thus potentially providing the most direct comparison between VA and non VA.30-32

These three papers, however, report on the same cohort of patients and are not able to compare 

actual disparities across VA and non-VA patients, since site of care is used primarily as an 

adjustment variable. Patients were collected from one prospective study of primary care clinics 

that referred patients to a VA medical center (serving Indiana and surrounding states) and from 

patients in a non-VA County hospital, which was near the VA, with primary care network and 

community health care centers (Indianapolis). Race was self-reported.

The primary outcomes of interest were racial disparities in clinical appropriateness, perceived 

health beliefs of TJR, and referral to an orthopedic surgeon. Outcomes were assessed using the 

medical record and self-report. The sample size varied slightly between reports, ranging from 

676 to 691. Approximately 90% of eligible subjects participated. The patient cohort comprised 

38% African Americans (AA) and 72% whites, all of whom had at least moderate osteoarthritis. 

Eligibility criteria included age (>50 y/o), radiographic evidence of osteoarthritis, and Western 

Ontario and McMaster Universities Osteoarthritis Index (WOMAC) summary score >=30. There 

were differences in the racial distribution of patients by recruitment site: 64% of the African 

American patients and 30% of whites were recruited from the county hospital 

Results showed no differences in clinical appropriateness for TJR between the racial groups: 

(appropriate for TJR: 25.5% AA versus 29.4% whites; inappropriate: 74.5% AA versus 

70.6% whites; P=0.3).31 Multivariate regression confirmed that race did not predict clinical 

appropriateness (OR=1.2 [0.8–1.8]; P=0.3). Clinical appropriateness was determined using an 

algorithm based on 5 variables: adequacy of medical management, WOMAC pain severity, 

WOMAC functional limitation, age (50–70 years or >70 years), and medical comorbidity. 

Patients were categorized as appropriate, uncertain, or inappropriate for TJR. Appropriate 

represented a patient who was severely symptomatic (pain and function) despite medical 

management, and could undergo surgery with acceptable risk. This validated algorithm show that 

appropriateness was associated with better health-related quality of life following TJR. There 

was no difference in clinical appropriateness between county and VA patients (28.8% versus 

27.2%, P=0.6). 

A similar analysis of 684 patients from this cohort looked at the association of race with health 

beliefs and barriers to TJR.32 This outcome was assessed using the modified Arthritis-related 

Health Belief Instrument (AHBI), based on the Health Belief Model. AHBI reports 4 themes: 

perceived arthritis severity, perceived susceptibility for arthritis to worsen, perceived benefits of 

arthroplasty, and perceived barriers to arthroplasty. This analysis identified differences in health 

beliefs and barriers to TJR. African American patients were less likely than whites to perceive 

benefits of TJR (OR=.60 [.42-.86]; P=.005) and more likely to recognize barriers to TJR (OR=1.7 

[1.18-2.44]; P=.004). The analysis did not find any racial differences in perceived arthritis severity 
16

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

or susceptibility that arthritis would worsen. Recruitment site was predictive of perceived benefits 

of TJR: County patients were less likely than VA patients to perceive benefits of TJR (OR=.45 

[.23-.89]; P=0.02). Hospital site (county versus VA) did not predict perception of barriers to THR 

(OR=1.38 [0.71-2.66]; P=.33). Race and hospital site interactions were not significant.

The third study assessed the same patient cohort (n=676); the primary outcome was referral to 

an orthopedic surgeon.30 Race, clinical appropriateness, and health beliefs were included in the 

analyses. Neither race (HR=1.39 [0.94–2.05]; P=0.1) nor any of the four health belief themes 

(HR range 0.99 to 1.05) predicted referral to a surgeon. However, clinical appropriateness did 

predict referral (HR=1.95 [1.15-3.32]; P=0.01). Regression models controlled for recruitment 

site (county versus VA). In a univariate analysis, non-VA patients were more likely to be referred 

to an orthopedic surgeon than were VA patients (60.5% compared with 39.5%, P<0.0001). 

Multivariate regression showed that county patients were more likely (HR=2.7 [1.4 –5.1], 

P=0.0026) than the VA patients to be referred to surgery. Interactions of race with hospital site, 

health beliefs, and clinical appropriateness were not significant. 

Summary of Findings

Only three studies combine both VA and non-VA patients and examine racial disparities in joint 

replacement, but they are not able to directly compare actual disparities across VA and nonVA sites. There were no racial differences in clinical appropriateness for TJR or differences 

in perceived arthritis severity or susceptibility for worsening. African American patients were 

less likely than whites to perceive benefits of and more likely to recognize barriers to TJR. 

There was no difference in clinical appropriateness for patients at a county hospital compared 

with patients at a nearby VA. Studies found that County hospital patients were nearly 3-fold 

more likely to be referred to a surgeon compared with VA patients, but this association was not 

significant when self-reported referral data were used. The quality of evidence for this conclusion 

is low because all data came from a single cohort, and replication of the results in other patient 

populations is needed in order to have stronger confidence in the conclusion.

VA Data

Each of the additional studies of joint replacement in VA comes from one of the other 6 patient 

cohorts, as described above (Table 2). All but one are small studies of patients in either one or 

two VA Medical Centers; the larger study used NSQIP data.28 Two studies had population-based 

or otherwise representative sampling of patients; the rest used convenience samples. Race was 

identified by self report except for the larger study, which used administrative data. Assessment 

of receipt of the procedure was a criterion that only applied in two of the studies, one using 

administrative data, the other using medical records. Response rates were not recorded for about 

half of the studies; in the remainder, response rates were high. 

In a majority of cases, the studies focused on patient factors that might explain racial disparities 

in procedure use, but in a few cases the studies deal with topics that overlap patient, provider, 

and health system factors as well as the clinical encounter (based on conceptual framework, 

Figure 2 above).

In one VA cohort, patients aged 50-79 with chronic knee or hip pain and WOMAC score 

greater than 38 were enrolled from primary care clinics at the Philadelphia and Pittsburgh VA 
17

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

Medical Centers between 2004 and 2006. The first study from this cohort33 examined racial 

differences in the pain coping strategies for 939 of these patients. This analysis found that, of 

the various coping strategies, blacks relied more on hoping and praying compared with whites 

(Beta = 0.74, 95% CI 0.50-0.99), and blacks were more likely to view prayer as helpful (OR 

3.38, 95% CI 2.35-4.86) and to have tried prayer (OR 2.28, 95% CI 1.66-3.13) to manage their 

pain. Groeneveld et al.34 report on a second study using the same cohort to examine racial 

differences in the expectations of the effectiveness of joint replacement in improving quality 

of life, measured using a validated survey scale (JRES). After adjusting for disease severity, 

socioeconomic factors, literacy, and trust, there were small but statistically significant differences 

in patient expectations, with blacks having lower expectations for both knee and hip OA. The 

authors note that the clinical and policy significance of these differences is not clear. 

Eight of the VA studies on racial disparities in joint replacement come from a cohort of 596 

patients from primary care clinics at the Cleveland VA in 1997-2000.36-43 Participants in 

the cohort were approached and asked about their hip/knee pain, and they were eligible for 

inclusion if they self-identified as white or black, were over age 50, and had at least moderate 

severity symptoms based on the Lequesne OA Severity Index. Each of the studies (which had 

considerable overlap in authorship) is described in more detail below. All focus on patient 

factors underlying joint replacement disparities; two also involve the overlap of patient and 

provider factors and the clinical encounter.

In the earliest study based on this cohort, Ibrahim et al.43 examined differences in the perceptions 

of the efficacy of traditional treatments and complementary treatments and self-care practices 

for osteoarthritis. In adjusted analyses, blacks were less likely to believe that joint replacement 

was efficacious compared with whites (OR 0.52, 95% CI 0.28-0.98) and were more likely to 

rely on self-care measures for their arthritis. The same authors published a second study42 that 

examined differences in the familiarity and knowledge of respondents about joint replacement 

within the same cohort; black patients were less likely than white patients to be familiar with 

joint replacement surgery (had ever heard of TJR or had family/friends with TJR or reported a 

‘good understanding’ of TJR) and more likely to express concerns about post-operative pain and 

walking ability. 

In a third study from the Cleveland VA cohort41 examining self-assessed quality of life, the same 

authors found that black race was associated with worsened quality of life; the analyses adjusted 

for WOMAC score, depression, and other clinical factors. In a fourth study, Ang et al.40 focused 

on the ‘helpfulness of prayer’ in the treatment of OA and how that belief affected attitudes 

towards arthroplasty. They found that black patients were more likely than whites to perceive 

prayer as helpful in the management of their arthritis (OR 2.1, 95% CI 1.19-3.72) and were less 

likely to consider surgery for severe arthritis pain (OR 0.59, 95% CI 0.34-0.99). The authors 

suggest that feelings about the helpfulness of prayer among black patients may explain part of 

the differences found in the rates of TJR among patients with osteoarthritis.

Two of the studies from the Cleveland VA cohort37, 38 describe differences in how pain is 

perceived between blacks and whites with osteoarthritis. Ang et al.37 examined differences 

in perceptions of pain and functional disability between blacks and whites at a given level of 

radiographic severity of arthritis. They found no differences in mean pain and function scores 
18

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

(from the WOMAC). The authors interpret these findings as evidence that differences in 

perceived symptoms do not explain the observed disparities in joint replacement. Ibrahim et al.38

report on an exploratory factor analysis in a subsample of these patients (300 veterans). They 

find a different factor structure in descriptions of pain among blacks and whites, and note that 

these descriptions of pain did not correlate with radiologic stage of disease. They suggest that 

blacks and whites with chronic joint osteoarthritis describe the quality of their pain differently.

Two final studies from this Cleveland cohort of 596 patients focus primarily on outcomes that 

involve considerable overlap between patient and provider factors and the clinical encounter. 

Ibrahim et al.39 report on racial differences in the willingness to consider surgery, familiarity 

with joint replacement surgery, and outcome expectations among patients with arthritis. Blacks 

had lower odds of having family/friends with TJR (OR 0.39, 95% CI 0.26-0.61) and lower odds 

of ever hearing of TJR (OR 0.64, 95% CI 0.37-1.09). They were also more likely than whites 

to expect a longer hospital course and moderate to severe pain and difficulty walking after 

TJR. Willingness to consider TJR was assessed using one question: “If your pain were to get 

severe, would you consider surgery to replace your knee/hip if your doctor recommended it?” 

After adjusting for demographic characteristics, clinical severity, and familiarity with surgery, 

blacks were less likely than whites to respond yes (OR 0.53, 95% CI 0.30-0.96). However, after 

adjusting for outcome expectations, the difference between blacks and whites in willingness 

to consider TKR was no longer significant (OR 0.86, 95% CI 0.45-1.63). Here the authors 

suggest that expectations of postsurgical course mediated the differences in willingness to have 

surgery. Lopez et al.36 examine referrals to specialists and satisfaction with care among this same 

cohort of patients with knee and/or hip OA. They find that blacks were less likely to view the 

quality of the primary care relationship as excellent (24.7% vs. 36.3%, p<.01) and less likely to 

receive a referral to an orthopedic surgeon (17.4% vs. 24.2%); the latter did not reach statistical 

significance (p = 0.06). In multivariate analyses adjusted for severity of disease, blacks had 

lower odds of referral to an orthopedic surgeon (OR 0.61, 95% CI 0.36-1.03), although the 

relationship only approached statistical significance. 

Four additional studies using different VA cohorts examine determinants of disparities in joint 

replacement that overlap between patient, provider, and clinical factors. In the second VA study 

using national data from the Veterans Administration National Surgical Quality Improvement 

Program (NSQIP), and the only study including Hispanic veterans, Ibrahim et al.28 report on 

the differences in outcomes between black, white and Hispanic veterans who undergo hip and 

knee arthroplasty between 1996 and 2000-6,703 patients and 12,108 patients respectively. They 

examine rates of risk-adjusted 30-day mortality and rates of both infectious and non-infectious 

complications. There were no racial/ethnic differences in 30-day mortality, although there were 

differences in complication rates. Black patients had higher infection and non-infection related 

complications following knee replacement (RR 1.42, 95% CI 1.06-1.90, and 1.50, 95% CI 

1.08-2.10, respectively.) Hispanic patients had a higher risk of infection (but not non-infection) 

related complications compared to whites (RR 1.64, 95% CI 1.08-2.49). There were no racial 

differences in hip arthroplasty complications.

Hausmann et al.26, 29 recruited patients immediately before and after their orthopedic surgery 

clinic visit at two large VA hospitals (Pittsburgh and Cleveland) between 2005 and 2008, and 

report on two separate studies. In the first,26 the primary outcome was whether patients received 
19

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

a recommendation for TJR from the surgeon, as determined by electronic medical record review. 

The authors found the odds of receiving a TJR recommendation were lower for blacks than for 

white patients of similar age and disease severity (OR 0.46, 95% CI 0.26-0.83); however, the 

difference was no longer significant after adjusting for patient preference for TJR (measured 

using a single item question). In the second study,29 Hausmann et al. analyzed audio recordings 

for 402 of the 526 patients in the cohort to examine racial differences in patient-provider 

communication about treatment of chronic knee and hip osteoarthritis. The authors found very 

little racial difference in patient-provider communication, including no difference in informed 

decision-making and no difference in visit length, provider or patient affect, or physician 

verbal dominance. The only 2 aspects of communication that differed were less discussion of 

biomedical topics and more rapport-building statements in visits with blacks compared with 

whites. The authors conclude that their findings argue against the idea that communication 

differences play a large role in explaining disparities in joint replacement.

Finally, a small pilot study testing an intervention designed to reduce joint disparities in VA44

contains data on baseline racial disparities. (The results of the intervention are described below.) 

The study included a convenience sample of 102 patients with moderate to severe osteoarthritis 

(WOMAC >39) recruited from the Greater Los Angeles VA Healthcare System. Baseline 

expectations about post-TKR outcome were lower for African American patients than for white 

patients regarding pain and physical function (P= 0.18 and P=0.13, respectively), although 

the results were not statistically significant. African American patients were also less likely to 

have ever heard of TKR compared with whites (49% vs. 72%, p=0.02), and less likely to know 

someone who had TKR (34% vs. 53%, p=0.05). There was no statistically significant difference 

in willingness to consider surgery at baseline (P=0.12).

Summary of Findings

Evidence about the patient-, provider-, and system- level factors that contribute to disparities in 

joint replacement surgery in the VA comes from a series of small studies recruiting patients from 

one or two VA medical centers. The studies find generally that black patients, compared with 

whites, have lower expectations about the effectiveness of joint replacement, less familiarity 

with the procedure, and may be more likely to view prayer and other techniques as useful for 

managing arthritis pain. There is some evidence that blacks may be less likely to be referred to 

specialists for joint replacement or to have TJR recommended by a specialist; however, some of 

these differences may be explained by patient preferences. One study examining communication 

between patients and orthopedic surgeons in the VA found little difference by race.

Although the individual studies are of high quality, the overall quality of evidence for the above 

conclusions is low because the studies were small and limited to a few sites. It is also likely that 

further research into important mediators (such as patient preference) and research with different 

patient cohorts will have an important impact on conclusions about the reasons for these joint 

disparities. The age of the data is also a limiting factor: a majority of the studies come from patient 

cohorts recruited over 10 years ago, and 8 of those studies come from a single VA medical center.

Data about reasons for disparities for other races (Hispanic, Asian) are scant, and no conclusions 

can be drawn. The quality of evidence is therefore very low.
20

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

Non-VA Data

A number of review articles have been published about reasons for disparities in health care in 

general and a few about osteoarthritis and pain in particular. Perhaps most notable is the Institute 

of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health 

Care.”63 This report concluded, with respect to “Assessing Potential Sources of Disparities in 

Care,” that:

• A small number of studies suggest that racial and ethnic minority patients are more likely 

than white patients to refuse care. These studies find the differences in refusal rates 

are generally small and that minority patient refusal does not fully explain health care 

disparities.

• Many sources, including health systems, healthcare providers, patients, and utilization 

managers - may contribute to racial and ethnic disparities in healthcare.

• Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers 

may contribute to racial and ethnic disparities in healthcare. While indirect evidence from 

several lines of research support this statement, a greater understanding of the prevalence 

and influence of these processes is needed and should be sought through research.

More recent review articles on disparities in general include that of King et al.,64 which expanded 

somewhat on the IOM review, and Klonoff ,65 which noted that “almost 35% of the national 

differences in arthroplasty rates for African-American women and almost 95% of the differences 

for Latino women appear to reflect that African-American and Latino women were more likely to 

live in areas of the country with lower rates of arthroplasty”. Saha et al.66 reviewed disparities in 

VA health care and categorized potential causes of disparities as patient medical knowledge and 

information sources, patient trust and skepticism, patient participation, patient social support and 

resources, clinician judgment, racial/cultural milieu, and healthcare facility characteristics. 

Reviews more specific to joint replacement include a section of a review by Anderson, Green and 

Payne67 on disparities in pain, which concluded that variability in decision-making in primary 

care as well as delay in surgical referral contributed to disparities in pain and post-operative 

outcomes; and a review by Allen68 on racial and ethnic disparities in osteoarthritis phenotypes, 

which concluded that knee osteoarthritis may be more common in African-Americans than in 

Caucasians in the United States, and that pain and problems with physical functioning is greater 

for African-Americans than for Caucasians with knee osteoarthritis. 

Set against this general background, we identified 20 studies of non-VA disparities in joint 

replacement surgery that we classified as second-generation studies. Of these, four were also 

included in the review by Kane and colleagues.69-72 These studies focused on a handful of topics 

including severity of OA, knowledge of joint replacement, perceived benefits and fear of surgery, 

consideration of surgery in the past, impact of socioeconomic factors, patient attitudes and 

beliefs, willingness-to-pay, referral to a surgeon, and receipt of surgery at a low volume hospital 

or by a low volume surgeon. An individual study could report on one or more of these topics. 

Eight studies looked at knowledge, perceived benefits, or fear of joint replacement surgery.57, 69-75 

Three studies assessing knowledge of or familiarity with joint replacement surgery found that, in 
21

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

general, African-Americans had less knowledge than whites or were less likely to have known 

someone who had undergone this surgery.69, 72, 75 African-Americans had greater fear before and 

after hip or knee arthroplasty than whites.74 Another study found that health beliefs differed by 

race/ethnicity. Trust was a critical issue for Hispanic patients, while overall economic issues 

were less important.74

In race-based focus groups, Whites, Hispanics, and African-Americans differed in their 

explanations of causal factors for OA, the change in lifestyle from OA, their trust of and 

skepticism about the physician, and payment for TKR.76 African-Americans reported low 

expectations that TKR would improve their joint pain or health,70 but there was no comparison 

race/ethnicity group in this particular study. Expectations about joint replacement surgery 

were lower among African-American men relative to white women, even after adjustment of 

socioeconomic factors.57 Whites were more likely to consider TKR surgery beneficial.69 One 

study using race concordant facilitators for focus groups suggested that differences in health 

beliefs and attitudes about surgery were primarily based on personal experiences; contrary to the 

other studies, the study concluded that African-Americans did not have more concerns/fears or 

worse expectations than whites.73 Another study’s qualitative interviews with black participants 

reinforce the findings that blacks had a preference for natural remedies, negative expectations 

of surgery, beliefs about God’s control, a preference for continuing in their current state, poor 

relationships with specialists, and fear of surgery or death.71 One of the above studies did not find 

differences in self-treatment for joint pain.75

Four studies assessed aspects of pre-operative and/or post-operative function across different 

racial groups.77-80 Two studies, one conducted at New York University hospital and another at 

University of Pennsylvania hospital, found that African Americans had worse pre-operative knee 

function compared with whites, and longer delays to presentation for surgery. African American 

women had worse post-operative function, but the incremental gain with joint replacement 

surgery was equivalent to whites. Both studies support the hypothesis that African American 

patients present for TKR in a more advanced state than whites, but that improvement in function 

is approximately equivalent. 

A third study examined the variation in family structure and social support between various 

racial groups after an individual had undergone hip fracture surgery or lower extremity joint 

replacement. The study found that whites and blacks were statistically significantly more 

likely to be responsible for their own care and discharged home alone than were Hispanics or 

Asians.79 These differences in family structure and social support appear to be related to outcome 

disparities, with Hispanic males being the least likely to report hospital readmission at follow-up. 

Similarly, the last study found that blacks and Hispanics were more likely to be discharged to 

home following hip replacement, with Hispanics showing a statistically significant difference.80

Men also had higher odds of being discharged to home. However, mean functional status change 

did not predict discharge disposition, suggesting that ethnic and gender disparities exist in THR 

care outcomes.

Three studies using administrative data (California State and New York City) found race/ethnic 

disparities for receipt of joint replacement surgery by a low volume hospital or low volume 

surgeon.81, 82 Liu82 found that African-Americans, Hispanics and Asians were more likely to 
22

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

receive TKR in low volume hospitals, controlling for socioeconomic factors, comorbidities and 

distance to hospital. SooHoo83 also found that minorities as compared to white patients were 

more likely to undergo THR in low volume hospitals. Using New York City data, Epstein found 

that African-Americans, Hispanics, and Asians were more likely to receive total hip replacement 

in either a low volume hospital or by a low volume surgeon, also controlling for socioeconomic 

factors and distance to hospital.81 These studies may support the hypothesis that “geography is 

destiny,” meaning that where patients seek care largely influences the kinds and amount of care 

they receive.

Willingness-to-pay methodology was used in two studies by the same author group (both 

included the same subset of patients for the random dialing component). They found that 

African-Americans had a lower willingness-to-pay for TKR than whites,84, 85 but differences were 

not significant in one study for Hispanics after adjusting for confounders.85

One study found that African-Americans patients were less likely to have seen an orthopedic 

surgeon for hip/knee surgery.75 Physicians were more likely to discuss TKR with minorities 

(African-Americans and Hispanics), but whites were more likely to consider having surgery.69

Ethnic differences remained after controlling for disease severity. African-Americans patients, 

especially women, had longer delays to getting TKR surgery.77

An old study (data from 1970s and 1980s) documents lower use of TKR among blacks compared 

with whites, even in the Medicaid-eligible or Medicare population, questioning whether 

economic factors alone explain the differences.11 Another more recent study using data from the 

Health and Retirement Survey from 1998-2004 also found that relative poverty or access to care 

did not explain disparities between blacks and whites in receipt of joint replacement.62

Overall these studies are of moderate quality, and the results across studies and procedures are 

relatively consistent. We found few studies on Hispanics and Asians, and as such the evidence is 

of low quality for them.

Summary of Findings

Evidence in non-VA settings suggests that minority patients (African Americans being the 

most studied) may have less knowledge about joint replacement surgery, perceive fewer health 

benefits, and have greater fear about the surgery, similar to findings within VA. These patients 

may be less likely to be referred to a surgeon and are less likely to consider surgery. When 

they do present for surgery, African Americans have more advanced disease. Disease severity, 

socioeconomic factors, or degree of comorbidities do not appear to account for all of these 

differences. Minority patients may be less likely to be treated in high volume centers or by high 

volume providers, which is a system-level factor that has not been studied within VA.

KEY QUESTION #3. What is the evidence regarding VA or non-VA 

interventions to reduce disparities in joint replacement surgery?

We identified only one study of an intervention designed to reduce joint disparities in VA.44 The 

authors assessed a decision aid that attempted to improve patient knowledge and expectations. 

The decision aid was a 45-minute videotape created by the Foundation for Informed Medical 

Decision Making about the treatment options for knee osteoarthritis, including total joint 
23

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

replacement. One hundred and two veterans from the Greater Los Angeles VA Healthcare 

System were recruited via flyers in VA clinics and waiting areas. Eligible subjects had to 

have moderate to severe osteoarthritis (as defined by the Western Ontario and McMaster 

Universities Osteoarthritis Index (WOMAC) of greater than 39) and have no significant medical 

comorbidities. Sixty-four subjects ended up watching the video, attending a focus group, and 

completing both pre- and post- video surveys about expectations regarding post-operative total 

knee replacement pain and function. 

Compared with Caucasians, African Americans had worse pre-video expectations of pain 

and function following total knee replacement. After watching the video, expectations were 

unchanged for Caucasian veterans. However, African American veterans had statistically 

significant improvements in their expectations for pain and function post-operatively (see Table 

3 below). The post-video expectations were therefore essentially the same for Caucasians and for 

African American veterans. The authors conclude that baseline disparities in expectations can be 

improved.

Table 3. Baseline and post-intervention total knee replacement expectations (n=64). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale 0-100, where higher scores 

reflect poorer expectations. Expected WOMAC Scores <-better poorer->

 Pain Function Pain Function

 Caucasian African American

Pre-Intervention

Post-Intervention

Summary of Findings

There has been only one published VA study of an intervention to improve disparities. It focused 

on expectations and examined only total knee replacement. Other potential causes of disparities 

have not been the subjects of interventions, and no study has yet assessed changes in the actual 

delivery of joint replacement surgery.

The quality of evidence for this key question is very low, due to sparseness of data; thus any 

estimate of effect is uncertain.

50

40

30

20

10

0
24

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

SUMMARY AND DISCUSSION

SUMMARY OF EVIDENCE BY KEY QUESTION

Key Question #1

What is the evidence about the existence and magnitude of disparities in joint replacement 

surgery in VA? How does this compare to published studies from non-VA US populations?

Data supporting existence of disparities in joint replacement surgery in VA are not very robust 

because they come from just three studies, two of which focus on racial disparities and one of 

which focuses on gender disparities. The magnitude of the racial disparities in VA as documented 

in these studies is about the same as the magnitude based on more extensive data from non-VA 

US populations (about 1.5-3 fold). The quality of evidence for this conclusion is low, based 

on sparseness and age of data. Thus we expect further research both into racial and gender 

disparities, to have an important impact on our estimate of the magnitude of disparities. 

The literature on racial disparities in total joint replacement outside the VA is more robust than 

within the VA. Studies of non-VA US populations consistently find that black patients receive 

fewer TKR operations than whites, and men receive fewer TKR operations than women. The 

quality of evidence for this conclusion is high; thus future research is unlikely to change our 

confidence about the estimate of effect. However, future research is still necessary to evaluate 

these disparities over time and assess whether they are increasing or decreasing.

There are fewer studies that examine whether differences in TKR rates represent true disparities 

based on clinical need. Those that have examined this issue conclude in general, but not 

consistently, that there are disparities based on clinical need between blacks and nonblacks. 

The quality of evidence for this conclusion is moderate. Further research is likely to affect our 

confidence in the estimate of disparities and may change the estimate.

Data about differences in utilization and disparities for total hip replacement in both non-VA 

US and VA populations are scant, and no conclusions can be drawn. The quality of evidence is 

therefore very low.

Data about differences in utilization for other races (Hispanic, Asian) are scant, and no 

conclusions can be drawn. The quality of evidence is therefore very low.

Key Question #2

What is the evidence about the patient level, provider level, and system level factors that 

contribute to disparities in joint replacement surgery in VA? How does this compare to published 

studies from non-VA populations?

Only three studies combine both VA and non-VA patients and examine racial disparities in joint 

replacement, but they are not able to directly compare actual disparities across VA and nonVA sites. In these studies, there were no racial differences in clinical appropriateness for TJR 

or differences in perceived arthritis severity or susceptibility for worsening. African American 

patients were less likely than whites to perceive benefits of and more likely to recognize barriers 

to TJR. There was no difference in clinical appropriateness for patients at a county hospital 
25

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

compared with patients at a nearby VA. Studies found that County hospital patients were nearly 

3-fold more likely to be referred to a surgeon compared with VA patients, but this association 

was not significant when self-reported referral data were used. The quality of evidence for this 

conclusion is low because all data came from a single cohort, and replication of the results in 

other patient populations is needed in order to have stronger confidence in the conclusion.

Evidence about the patient-, provider-, and system- level factors that contribute to disparities in 

joint replacement surgery in the VA comes from a series of small studies recruiting patients from 

one or two VA medical centers. The studies find generally that black patients, compared with 

whites, have lower expectations about the effectiveness of joint replacement, less familiarity 

with the procedure, and may be more likely to view prayer and other techniques as useful for 

managing arthritis pain. There is some evidence that blacks may be less likely to be referred to 

specialists for joint replacement or to have TJR recommended by a specialist; however, some of 

these differences may be explained by patient preferences. One study examining communication 

between patients and orthopedic surgeons in the VA found little difference by race. 

Although the individual studies are of high quality, the overall quality of evidence for the above 

conclusions is low because the studies were small and limited to a few sites. It is also likely that 

further research into important mediators (such as patient preference) and research with different 

patient cohorts will have an important impact on conclusions about the reasons for these joint 

disparities. The age of the data is also a limiting factor: a majority of the studies come from patient 

cohorts recruited over 10 years ago, and 8 of those studies come from a single VA medical center.

Data about reasons for disparities for other races (Hispanic, Asian) are scant, and no conclusions 

can be drawn. The quality of evidence is therefore very low.

Evidence in non-VA settings suggests that minority patients (African Americans being the 

most studied) may have less knowledge about joint replacement surgery, perceive fewer health 

benefits, and have greater fear about the surgery, similar to findings within VA. These patients 

may be less likely to be referred to a surgeon and are less likely to consider surgery. When 

they do present for surgery, African Americans have more advanced disease. Disease severity, 

socioeconomic factors, or degree of comorbidities do not appear to account for all of these 

differences. Minority patients may be less likely to be treated in high volume centers or by high 

volume providers, which is a system-level factor that has not been studied within VA.

Key Question #3

What is the evidence regarding VA or non-VA interventions to reduce disparities in joint 

replacement surgery?

There has been only one published VA study of an intervention to improve disparities. It 

focused on expectations and examined only total knee replacement. It found that, after watching 

an informational video, African Americans, but not Caucasians, had statistically significant 

improvements in their expectations for pain and function post-operatively. Other potential causes 

of disparities have not been the subjects of interventions, and no study has yet assessed changes 

in the actual delivery of joint replacement surgery.

The quality of evidence for this key question is very low, due to sparseness of data; thus any 

estimate of effect is uncertain.
26

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

LIMITATIONS

Publication Bias

Our literature search procedures were extensive and included canvassing experts from academia 

regarding studies we may have missed. It was not possible to conduct formal tests for publication 

bias, but even with such tests it is not possible to exclude the possibility that such bias exists. 

Therefore, readers are cautioned about this possibility.

Study Quality

An important limitation common to systematic reviews is the quality of the original studies. 

We did not identify any randomized studies. For non-randomized studies, we adapted from the 

Newcastle Ottawa Scale those criteria most applicable to our purposes, namely items about 

the representativeness of the enrolled population, the potential for misclassification bias in the 

identification of race, gender, or receipt of procedure, and the response rate or follow-up rate. 

Several studies that used non-VA data were based on nationally representative populations. This 

was in general not the case for the VA studies, which tended to be from one or two institutions.

Types of Factors Evaluated

Almost all studies of factors potentially contributing to disparities were of patient or providerlevel factors. System-level factors that are amenable to quality improvement activities, such as 

waiting times, have rarely been addressed.

Applicability of Findings to the VA Population

For the VA studies we assessed, the results are directly applicable to the VA population. 

However, as noted, the studies were generally restricted to only one or two centers.

Types of Disparities Represented in the Literature

While our search for disparities was broad, we identified a body of literature that deals 

primarily with disparities in race and gender. Other potential disparities, such as educational and 

socioeconomic factors, have been largely unstudied.

RECOMMENDATIONS FOR FUTURE RESEARCH

More research is needed in VA. The one national study of disparities in joint replacement in 

VA27 contain data from over 10 years ago and focused on knee replacement only, and the second 

uses more recent data26 but includes individuals referred to orthopedic clinics at two VA (with 

borderline statistical significance for the finding of racial disparities after statistical adjustment). 

Most VA second-generation studies are from limited samples and are over ten years old. The 

reviewed VA studies were well-designed, but a better and more current understanding of the 

reasons for the observed disparities is needed in order to design third-generation intervention 

studies that are most likely to succeed. In addition, with the increasing number of women and 

Hispanic veterans, planning now to better understand their potential need for TJR in the future is 

warranted.

In specific, VA could consider assessing the current utilization of TJR in a national or 

representative sample of veterans and VISNs, to first establish the magnitude of any differences 
27

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

in utilization in TJR between male and female veterans and those of different races. Second, 

presuming current data confirm the presence of different utilization rates, an in-depth 

examination should be performed of the degree to which these may be confounded by other 

factors, in other words asses “need” for joint replacement. Third, presuming that, even after 

adjusting for confounders, there still exists differential utilization among Veterans of different 

gender and ethnicity with the same “need,” mixed-method types of research will be necessary to 

help establish the causes and barriers that are contributing to this disparity. This research should 

examine, in addition to patient and provider level factors, the kinds of system level factors that 

are particularly amenable to the types of quality improvement initiatives that VA can implement 

well, due to its organizational structure. Lastly, based on the results of all the above, VA should 

test interventions to diminish disparities, addressing the need for third generation work, and 

implement those found effective nationally.
28

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

REFERENCES

1. DuBard, C. A., et al., Racial/ethnic differences in quality of care for North Carolina Medicaid recipients. N C Med J, 2009. 70(2): p. 96-101.

2. Lillie-Blanton, M., et al., Race, ethnicity, and the health care system: public perceptions 

and experiences. Med Care Res Rev, 2000. 57 Suppl 1: p. 218-35.

3. Consensus development conference statement: total knee replacement. 2003, National 

Institute of Health.

4. Kane, R. L., et al., Total knee replacement. Evidence Report/Technology Assessment No. 

86 (Prepared by the Minnesota Evidence-based Practice Center, Minneapolis, MN). in 

AHRQ Publication. 2003, Agency for Healthcare Research and Quality: Rockville, MD. 

No. 04-E006-2.

5. NIH consensus conference: total hip replacement. NIH consensus development panel on 

total hip replacement. JAMA, 1995. 273: p. 1950-1956.

6. Hochberg, M. C., et al., Guidelines for the medical management of osteoarthritis. Part II. 

Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum, 1995. 

38(11): p. 1541-6.

7. Dieppe, P., et al., Knee replacement surgery for osteoarthritis: effectiveness, practice 

variations, indications and possible determinants of utilization. Rheumatology (Oxford), 

1999. 38(1): p. 73-83.

8. Escarce, J. J., et al., Racial differences in the elderly’s use of medical procedures and 

diagnostic tests. Am J Public Health, 1993. 83(7): p. 948-54.

9. Baron, J. A., et al., Total hip arthroplasty: use and select complications in the US Medicare population. Am J Public Health, 1996. 86(1): p. 70-2.

10. Sharkness, C. M., et al., Prevalence of artificial hip implants and use of health services by 

recipients. Public Health Rep, 1993. 108(1): p. 70-5.

11. Wilson, M. G., D. S. May and J. J. Kelly, Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis, 1994. 4(1): p. 57-67.

12. Hoaglund, F. T., C. S. Oishi and G. G. Gialamas, Extreme variations in racial rates of 

total hip arthroplasty for primary coxarthrosis: a population-based study in San Francisco.

Ann Rheum Dis, 1995. 54(2): p. 107-10.

13. Katz, J. N., et al., Can comorbidity be measured by questionnaire rather than medical 

record review? Med Care, 1996. 34(1): p. 73-84.

14. Giacomini, M. K., Gender and ethnic differences in hospital-based procedure utilization 

in California. Arch Intern Med, 1996. 156(11): p. 1217-24.
29

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

15. Escalante, A., et al., Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum, 

2000. 43(2): p. 390-9.

16. Mehrotra, C., et al., Trends in total knee replacement surgeries and implications for public health, 1990-2000. Public Health Rep, 2005. 120(3): p. 278-82.

17. Ibrahim, S. A., Racial variations in the utilization of knee and hip joint replacement: an 

introduction and review of the most recent literature. Curr Orthop Pract. 21(2): p. 126-

131.

18. Morgan, R. C., Jr. and J. Slover, Breakout session: Ethnic and racial disparities in joint 

arthroplasty. Clin Orthop Relat Res. 469(7): p. 1886-90.

19. Singh, J. A., Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J. 5: p. 80-5.

20. Kane, R. L., et al., Disparities in total knee replacements: a review. Arthritis Rheum, 

2007. 57(4): p. 562-7.

21. Wennberg, J. E., The geography of health care in the United States, in The Dartmouth 

atlas of health care, J. E. Wennberg and C. M. McAndrew, Editors. 1996, American Publishing, Inc.: Chicago. p. 11-35.

22. Wennberg, J. E., Dealing with medical practice variations: a proposal for action. Health 

Aff (Millwood), 1984. 3(2): p. 6-32.

23. Jadad, A. R., et al., Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials, 1996. 17(1): p. 1-12.

24. Wells, G., et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses 2000; Available from: http://www.ohri.ca/programs/

clinical_epidemiology/oxford.asp.

25. 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.

26. Hausmann, L. R., et al., The Effect of Patient Race on Total Joint Replacement Recommendations and Utilization in the Orthopedic Setting. J Gen Intern Med, 2010.

27. Jones, A., et al., Racial disparity in knee arthroplasty utilization in the veterans health 

administration. Arthritis Rheum, 2005. 53(6): p. 979-81.

28. Ibrahim, S. A., et al., Racial/ethnic differences in surgical outcomes in veterans following 

knee or hip arthroplasty. Arthritis Rheum, 2005. 52(10): p. 3143-51.

29. Hausmann, L. R., et al., Orthopedic communication about osteoarthritis treatment: does 

patient race matter? Arthritis Care Res, 2011. 63(5): p. 635-642.

30. Ang, D. C., G. James and T. E. Stump, Clinical appropriateness and not race predicted 

referral for joint arthroplasty. Arthritis Rheum, 2009. 61(12): p. 1677-85.
30

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

31. Ang, D. C., et al., African Americans and Whites are equally appropriate to be considered 

for total joint arthroplasty. J Rheumatol, 2009. 36(9): p. 1971-6.

32. Ang, D. C., P. O. Monahan and T. A. Cronan, Understanding ethnic disparities in the use 

of total joint arthroplasty: application of the health belief model. Arthritis Rheum, 2008. 

59(1): p. 102-8.

33. Jones, A. C., et al., Investigating racial differences in coping with chronic osteoarthritis 

pain. J Cross Cult Gerontol, 2008. 23(4): p. 339-47.

34. Groeneveld, P. W., et al., Racial differences in expectations of joint replacement surgery 

outcomes. Arthritis Rheum, 2008. 59(5): p. 730-7.

35. Weng, H. H. and J. Fitzgerald, Current issues in joint replacement surgery. Curr Opin 

Rheumatol, 2006. 18(2): p. 163-9.

36. Lopez, J. P., et al., Patient perceptions of access to care and referrals to specialists: a comparison of African-American and white older patients with knee and hip osteoarthritis. J 

Natl Med Assoc, 2005. 97(5): p. 667-73.

37. Ang, D. C., et al., Is there a difference in the perception of symptoms between african 

americans and whites with osteoarthritis? J Rheumatol, 2003. 30(6): p. 1305-10.

38. Ibrahim, S. A., et al., Older patients’ perceptions of quality of chronic knee or hip pain: 

differences by ethnicity and relationship to clinical variables. J Gerontol A Biol Sci Med 

Sci, 2003. 58(5): p. M472-7.

39. Ibrahim, S. A., et al., Differences in expectations of outcome mediate African American/

white patient differences in “willingness” to consider joint replacement. Arthritis Rheum,

2002. 46(9): p. 2429-35.

40. Ang, D. C., et al., Ethnic differences in the perception of prayer and consideration of joint 

arthroplasty. Med Care, 2002. 40(6): p. 471-6.

41. Ibrahim, S. A., et al., Self-assessed global quality of life: a comparison between AfricanAmerican and white older patients with arthritis. J Clin Epidemiol, 2002. 55(5): p. 512-7.

42. Ibrahim, S. A., et al., Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patient-level factors. Med Care, 2002. 40(1 Suppl): p. 

I44-51.

43. Ibrahim, S. A., et al., Variation in perceptions of treatment and self-care practices in 

elderly with osteoarthritis: a comparison between African American and white patients.

Arthritis Rheum, 2001. 45(4): p. 340-5.

44. Weng, H. H., et al., Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum, 2007. 57(4): p. 568-75.

45. Borrero, S., et al., Brief report: Gender and total knee/hip arthroplasty utilization rate in 

the VA system. J Gen Intern Med, 2006. 21 Suppl 3: p. S54-7.
31

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

46. Hawker, G. A., et al., Differences between men and women in the rate of use of hip and 

knee arthroplasty. N Engl J Med, 2000. 342(14): p. 1016-22.

47. Skinner, J., et al., Racial, ethnic, and geographic disparities in rates of knee arthroplasty 

among Medicare patients. N Engl J Med, 2003. 349(14): p. 1350-9.

48. Escalante, A., et al., Disparity in total hip replacement affecting Hispanic Medicare beneficiaries. Med Care, 2002. 40(6): p. 451-60.

49. Katz, B. P., et al., Demographic variation in the rate of knee replacement: a multi-year 

analysis. Health Serv Res, 1996. 31(2): p. 125-40.

50. McBean, A. M. and M. Gornick, Differences by race in the rates of procedures performed 

in hospitals for Medicare beneficiaries. Health Care Financ Rev, 1994. 15(4): p. 77-90.

51. Racial disparities in total knee replacement among Medicare enrollees--United States, 

2000-2006. MMWR Morb Mortal Wkly Rep, 2009. 58(6): p. 133-8.

52. Jha, A. K., et al., Racial trends in the use of major procedures among the elderly. N Engl 

J Med, 2005. 353(7): p. 683-91.

53. Skinner, J., W. Zhou and J. Weinstein, The influence of income and race on total knee 

arthroplasty in the United States. J Bone Joint Surg Am, 2006. 88(10): p. 2159-66.

54. Hawkins, K., et al., Disparities in Major Joint Replacement Surgery among Adults with 

Medicare Supplement Insurance. Popul Health Manag.

55. Jain, N. B., et al., Trends in epidemiology of knee arthroplasty in the United States, 1990-

2000. Arthritis Rheum, 2005. 52(12): p. 3928-33.

56. Bang, H., et al., Total hip and total knee arthroplasties: trends and disparities revisited.

Am J Orthop (Belle Mead NJ). 39(9): p. E95-102.

57. Hanchate, A. D., et al., Exploring the determinants of racial and ethnic disparities in total 

knee arthroplasty: health insurance, income, and assets. Med Care, 2008. 46(5): p. 481-8.

58. Olson, J. C. and J. Foland, Tracking racial and ethnic disparities of knee replacement 

rates in Connecticut. Conn Med, 2005. 69(4): p. 211-5.

59. Basu, J. and L. R. Mobley, Trends in racial disparities among the elderly for selected procedures. Med Care Res Rev, 2008. 65(5): p. 617-37.

60. Oishi, C. S., et al., Total hip replacement rates are higher among Caucasians than Asians 

in Hawaii. Clin Orthop Relat Res, 1998(353): p. 166-74.

61. Francis, M. L., et al., Joint replacement surgeries among medicare beneficiaries in rural 

compared with urban areas. Arthritis Rheum, 2009. 60(12): p. 3554-62.

62. Steel, N., et al., Racial disparities in receipt of hip and knee joint replacements are not explained by need: the Health and Retirement Study 1998-2004. J Gerontol A Biol Sci Med 

Sci, 2008. 63(6): p. 629-34.
32

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

63. Unequal Treament: Confronting Racial and Ethnic Disparities in Health Care. Institute 

of Medicine, ed. B. D. Smedley, A. Y. Stith and A. R. Nelson. 2002, Washington, DC: National Academy Press.

64. King, R. K., et al., A plan for action: key perspectives from the racial/ethnic disparities 

strategy forum. Milbank Q, 2008. 86(2): p. 241-72.

65. Klonoff, E. A., Disparities in the provision of medical care: an outcome in search of an 

explanation. J Behav Med, 2009. 32(1): p. 48-63.

66. Saha, S., et al., Racial and ethnic disparities in the VA health care system: a systematic 

review. J Gen Intern Med, 2008. 23(5): p. 654-71.

67. Anderson, K. O., C. R. Green and R. Payne, Racial and ethnic disparities in pain: causes 

and consequences of unequal care. J Pain, 2009. 10(12): p. 1187-204.

68. Allen, K. D., Racial and ethnic disparities in osteoarthritis phenotypes. Curr Opin Rheumatol. 22(5): p. 528-32.

69. Suarez-Almazor, M. E., et al., Ethnic variation in knee replacement: patient preferences 

or uninformed disparity? Arch Intern Med, 2005. 165(10): p. 1117-24.

70. Figaro, M. K., P. Williams-Russo and J. P. Allegrante, Expectation and outlook: the 

impact of patient preference on arthritis care among African Americans. J Ambul Care 

Manage, 2005. 28(1): p. 41-8.

71. Figaro, M. K., P. W. Russo and J. P. Allegrante, Preferences for arthritis care among urban 

African Americans: “I don’t want to be cut”. Health Psychol, 2004. 23(3): p. 324-9.

72. Chang, H. J., et al., Concerns of patients actively contemplating total knee replacement: 

differences by race and gender. Arthritis Rheum, 2004. 51(1): p. 117-23.

73. Suarez-Almazor, M. E., et al., A qualitative analysis of decision-making for total knee 

replacement in patients with osteoarthritis. J Clin Rheumatol, 2010. 16(4): p. 158-63.

74. Lavernia, C. J., J. C. Alcerro and M. D. Rossi, Fear in arthroplasty surgery: the role of 

race. Clin Orthop Relat Res, 2010. 468(2): p. 547-54.

75. Blake, V. A., et al., Racial differences in social network experience and perceptions of 

benefit of arthritis treatments among New York City Medicare beneficiaries with selfreported hip and knee pain. Arthritis Rheum, 2002. 47(4): p. 366-71.

76. Kroll, T. L., et al., “Keep on truckin’” or “It’s got you in this little vacuum”: race-based 

perceptions in decision-making for total knee arthroplasty. J Rheumatol, 2007. 34(5): p. 

1069-75.

77. Kamath, A. F., et al., Ethnic and Gender Differences in the Functional Disparities after 

Primary Total Knee Arthroplasty. Clin Orthop Relat Res, 2010.
33

A Comparison of Joint Replacement Disparities in VA 

and Non-VA Settings: A Systematic Review Evidence-based Synthesis Program

78. Slover, J. D., M. G. Walsh and J. D. Zuckerman, Sex and race characteristics in patients 

undergoing hip and knee arthroplasty in an urban setting. J Arthroplasty, 2010. 25(4): p. 

576-80.

79. Ottenbacher, K. J., et al., Disparity in health services and outcomes for persons with hip 

fracture and lower extremity joint replacement. Med Care, 2003. 41(2): p. 232-41.

80. Berges, I. M., et al., Gender and ethnic differences in rehabilitation outcomes after hipreplacement surgery. Am J Phys Med Rehabil, 2008. 87(7): p. 567-72.

81. Epstein, A. J., B. H. Gray and M. Schlesinger, Racial and ethnic differences in the use of 

high-volume hospitals and surgeons. Arch Surg, 2010. 145(2): p. 179-86.

82. Liu, J. H., et al., Disparities in the utilization of high-volume hospitals for complex surgery. JAMA, 2006. 296(16): p. 1973-80.

83. SooHoo, N. F., E. Farng and D. S. Zingmond, Disparities in the utilization of high-volume hospitals for total hip replacement. J Natl Med Assoc. 103(1): p. 31-5.

84. Byrne, M. M., et al., Racial/ethnic differences in preferences for total knee replacement 

surgery. J Clin Epidemiol, 2006. 59(10): p. 1078-86.

85. Byrne, M. M., K. J. O’Malley and M. E. Suarez-Almazor, Ethnic differences in health 

preferences: analysis using willingness-to-pay. J Rheumatol, 2004. 31(9): p. 1811-8.