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
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A Comparison of Joint Replacement Disparities in VA 

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

EXECUTIVE SUMMARY

The purpose of this systematic review was to compare what is known about disparities in total 

joint replacement (TJR) surgery in VA settings with disparities in civilian health care settings.

BACKGROUND

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

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

function, and alleviate symptoms. When conservative treatments fail, surgical intervention is 

indicated. The most effective surgical option for moderate to severe osteoarthritis in the knee or 

hip is total joint replacement (TJR). TJR is often considered appropriate in cases where other 

non-surgical treatments have not brought adequate relief. TJR in the management of end-stage 

osteoarthritis is widely utilized and is considered the fastest growing elective surgery in the 

nation, if not the world. 

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

substantial evidence that disparities exist in TJR utilization in non-VA settings, with racial 

and ethnic disparities being the most documented. This report compares what is known about 

disparities in TJR in the VA context with disparities in non-VA settings.

The review focused on three key questions:

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?

METHODS

We searched PubMed from 1966 through July 2011 using standard search terms. We limited 

the search to PubMed articles involving human subjects and published in the English language. 

Titles, abstracts, and articles were reviewed in duplicate by physicians trained in the critical 

analysis of literature. We used a standardized screening form to screen abstracts and a data 

abstraction form to extract data from full articles. All data were narratively summarized.

Data about study characteristics, patient characteristics, and outcomes were extracted by a trained 

research associate under the supervision of the Principal Investigators--one a general surgeon, the 

other a general internist. Both are experienced reviewers. We assessed study quality for clinical 

trials using the Jadad criteria, and used a modified version of the Newcastle Ottawa Scale (NOS) 

for non-randomized studies.
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A Comparison of Joint Replacement Disparities in VA 

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

DATA SYNTHESIS

We constructed evidence tables showing key study and patient characteristics, methodological 

quality, and outcomes. We analyzed studies to compare their characteristics, methods, and 

findings. We compiled a summary of findings for each question based on qualitative synthesis of 

the findings. 

PEER REVIEW

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

leadership. We addressed reviewer comments and incorporated our responses in the final report 

(Appendix E).

RESULTS

We screened 299 titles, rejected 155, and performed a more detailed review on 144 articles. 

From these, we identified 75 articles that addressed one or more of the key questions: 25 

addressed key question #1, 38 addressed key question #2, and one addressed key question #3.

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 total knee replacement (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.
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A Comparison of Joint Replacement Disparities in VA 

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

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 evidence 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 

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 
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A Comparison of Joint Replacement Disparities in VA 

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

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.

ABBREVIATIONS TABLE

Table 1. Abbreviations

Abbreviation Definition

OA Osteoarthritis

THR Total Hip Replacement

TKR Total Knee Replacement

TJR Total Joint Replacement (TJR is also used for Total Joint Arthroplasty, which is 

sufficiently similar)