34

A Comparison of Joint Replacement Disparities in VA 

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

APPENDIX A. Search Strategy

HIP & KNEE REPLACEMENT – DISPARITIES

DATABASE SEARCHED: 

 PubMed

TIME PERIOD COVERED: 1966-2010

LANGUAGE: 

 ENGLISH

SEARCH STRATEGY:

arthroplasty, replacement, hip OR arthroplasty, replacement, knee OR arthritis/surgery OR 

osteoarthritis, knee/surgery OR osteoarthritis, hip/surgery OR (hip AND surger*( OR (knee AND 

surger*) OR (joint AND replac*) OR (knee AND replac*) OR (hip AND replac*) OR (joint AND 

arthroplast*) OR (hip AND arthroplast*) OR (knee AND arthroplast*)

AND

minority groups OR african americans OR hispanic americans OR african continental ancestry 

group OR racial OR ethnic OR minorities OR gender OR sex OR age[ti] OR age distribution

AND

disparity OR disparities OR difference* OR variation*
35

A Comparison of Joint Replacement Disparities in VA 

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

APPENDIX B. Study Selection Form

Article ID: Reviewer: 

Authors:

Title:

1. What type of joint replacement is discussed?

(Check all that apply)

Total Knee Replacement (TKR) .............

Total Hip Replacement (THR)................

Other: (specify__________________)...

None........................................................

If None Stop

2. What type of disparity is discussed?

(Check all that apply)

Racial/ethnic............................................

Gender.....................................................

Urban/rural..............................................

Regional ..................................................

Socioeconomic status..............................

Other: (specify__________________)...

Not clear, needs further review ...............

None........................................................

If None Stop

3. Which generation of study does this best fit?

(See explanation below for reference)

First .........................................................

Second.....................................................

Third........................................................

• First-Generation studies document the 

existence and the magnitude of the disparities.

• Second-generation studies examine the 

reasons for observed disparities and could 

be classified as: a) patient-level factors 

(treatment preferences, patterns of self-care, 

etc.); b) provider-level factors (physicianpatient communication, etc.); and c) system 

level factors (access to specialist care, etc.).

• Third-generation studies examine interventions

to address the observed disparities.

5. Are veterans discussed, either as the main 

focus or as a sub-category? 

Main focus...............................................

Sub-category ...........................................

No mention..............................................

6. What is the study design? 

Descriptive/observational........................

Experimental...........................................

Qualitative...............................................

Systematic review or Meta-Analysis......

Other........................................................

7. What is the approximate sample size?

<100 ........................................................

100-500 ...................................................

>500 ........................................................

8. Study origin?

Unclear....................................................

US............................................................

Non-US ...................................................

 Specify: __________

9. Mark as Background Article ...................
36

A Comparison of Joint Replacement Disparities in VA 

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

APPENDIX C. Data Extraction Form

ID: Reviewer: 

Author: 

Title: 

1. Is the study based solely in the US?

Yes..................................................................

No........................................................  STOP

2. Does the article examine an intervention to 

address the 

Yes..................................................................

If Yes, specify:___________________

No...................................................................

3. What is the data source for the study? (check 

all that apply)

a. Single institution ........................................

b. Multi-institutional (Regional) ....................

c. Multi-institutional (National) .....................

d. VA (single or multi-VA) .............................

e. Medicare .....................................................

f. Medicaid .....................................................

g. NIS ...... ....................................................

h. Other (Specify:_____________)................

4. Who are the primary study subjects? (check all)

a. Patients .......................................................

b. Providers.....................................................

c. Other...........................................................

5. How were patients selected?

a. Population-based/systematic/representative ..

 sample... ....................................................

b. Consecutive patients...................................

c. Convenience/non-representative sample ....

d. Combination of above ................................

e. Unclear/unknown .......................................

6. Years of data collection covered*: ________

7. What is the study design?

a. Cross-sectional........................................

b. Cohort/Case-control.................................

c. Experimental ............................................

d. Systematic Review...................................

e. Unclear/unknown .....................................

f.Background ..................................... STOP

8. What is/are the Primary Outcome Measure(s)?

a. Receipt of procedure(s)............................

b.Recommendation for procedure(s) ..........

c. Outcome of Procedure .............................

d. Appropriateness for Procedure ................

e. Perception of Need for Surgery ...............

f. Willingness to Consider Surgery .............

g. Outcome Expectations of Surgery ...........

h. Other ........................................................

 Specify: ___________________________

 Specify: ___________________________

9. What is/are the Secondary Outcome 

Measure(s)?

a. Receipt of procedure(s)............................

b. Recommendation For procedure(s)..........

c. Outcome of Procedure .............................

d. Appropriateness for Procedure ................

e. Perception of Need for Surgery ...............

f.Willingness to Consider Surgery...............

g. Outcome Expectations of Surgery ...........

h. Not Applicable .........................................

i.Other..........................................................

 Specify: _________________________

 Specify: _________________________

 Specify: _________________________
37

A Comparison of Joint Replacement Disparities in VA 

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

10. For Race: How was race categorized?

a.White.......................................................

b.Black .......................................................

c.Hispanic ..................................................

d.Asian .......................................................

e.Non-black................................................

f. Non-white................................................

g.None ........................................................

11.For Race: How was race determined?

a.Administrative data ................................ 

b.Medical record review............................ 

c.Self-reported........................................... 

d.Two or more sources .............................. 

e.Unknown or not reported........................ 

12. Assessment of receipt of procedure

a.Medical record .......................................

b.Administrative data ................................

c.Self report...............................................

d.Not reported/unknown ...........................

e.Not applicable ........................................

13. Assessment of primary disparity outcome 

(function, quality of life, receipt of 

procedure, etc)

a.Medical record .......................................

b.Administrative data ................................

c.Self report...............................................

d.Not reported/unknown ...........................

14. Population sample size: 

a.Total_____________________________

b.Veteran sample size ________________

15. What was the mean/median age of the 

patients*?

______________________________

16. Response Rate

a.Number Eligible for Study

_________________

b.Number Declining Participation

_________________

c.Response Rate if Reported____________

d.Unclear/unspecified................................

e.Not applicable ........................................

17. Adequacy of follow-up for subjects?

a. Complete follow-up of all subjects ........

b. Subjects lost to follow-up.......................

If so, # _______ or % _____ f/u

c. Description of those lost to f/u ..............

d. Unclear/unspecified................................

e. Not applicable.........................................

18. If results were adjusted, were the following 

covariates included?

a.Age ..........................................................

b.Gender.....................................................

c.Income.....................................................

d.Education.................................................

e.Insurance .................................................

f. Not Applicable ........................................

19. For Race: How many “unknowns” were 

reported?

a.Total or percent “unknown” ........ _______

b.Not reported ...........................................

*No data denoted as 999
38

A Comparison of Joint Replacement Disparities in VA 

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

APPENDIX D. Newcastle Ottawa Scale Criteria Used in 

Quality Assessment

Selection

1) Representativeness of the exposed cohort

2) Ascertainment of exposure

3) Demonstration that outcome of interest was not present at start of study

Comparability

1) Comparability of cohorts on the basis of the design or analysis

Outcome

1) Assessment of outcome 

2) Was follow-up long enough for outcomes to occur

3) Adequacy of follow up of cohorts
39

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

eer Review Comments/Author Responses

Comment Response

ess to orthopedics consultations, etc. have not been clearly documented, 

elate to some of the differences observed. If these barriers indeed exist, they 

ality improvement measures.

There is a new section in the limitations that addresses this.

ntly After double-checking for inconsistencies, some 

remain due to the literature itself.

ritis Care & Rheum 2011, p635-642 Now included, found in update search

ings’ sections read better than the ‘data’ sections. The data sections need 

ections should be directed at reading fluency to better convey the intended 

ttention to writing, paragraph structure, style, grammar, and typographical 

Edits have been made to address this issue.

re-search, using the same database and keywords, for the period from 

final update prior to publication.

Update is now included

the level of evidence available to make any decisions of consequence.

tion of the levels, it appears that most cited studies are at minimum a level 

document by the standard definitions and the numerical system to be sure 

n addition, grades of recommendation for the consensus should use a standard 

gain for clarity. When levels of evidence are so low or the mass of supporting 

ndation can only be I, the only conclusion would be we need focused research 

g more. In this current context, the supposed disparity may have no other basis 

l beliefs and population bias which may not be alterable.

The ESP program uses the GRADE system, which does not use the level I, II, III approach. The limitations of the evidence are reflected in the overall “quality of evidence,” and most of these are rated as low or very low.

 with respect to results. Since many individuals may only access the 

ary of results would be appropriate, such as including how many studies were 

 and whether they included or not VA populations. In general, the findings are 

most....’. Including number of studies and participants would be useful. This 

t, but would be useful in the summary.

We have revised the executive summary to include more detail

disparities” in TJR use in non-VA settings. It would be useful here to mention 

g alluded to (e.g., race, gender, ethnicity...)

This paragraph has been updated to be more specific.

ragraph notes that future research is unlikely to change confidence on 

ould be qualified here (and elsewhere in the synthesis where this is also 

is still important for evaluating whether there are any temporal trends in 

e over time in response to any policies, interventions, etc).

Very good point, we have updated the relevant sections accordingly.
40

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

Comment Response

mary----it would be nice in the summary to add the number of studies 

 each KQ

These numbers have been added at the beginning of the results section.

age 5, and elsewhere the report refers to “disparities.” This description is 

nly addresses gender and racial disparities. Clarification of this usage to use 

acial disparities” in place of “disparities” is suggested.

We revised the draft to clarify.

arch papers which primarily address only two racial / ethnic groups (White, 

’t clearly address educational, socioeconomic and regional effects.

This is a limitation of the primary literature. Almost all the disparity literature deals with gender and race. Even within gender disparities, VA data are very scarce. These additional potential sources of disparities are now noted in the limitations.

eviewed’ articles. How is this assessed? Do the authors mean original 

ncluded, how was it determined if they were peer-reviewed

We revised this to indicate that anything indexed on PubMed was potentially eligible

he heading ‘search strategy’ more detailed description of the search terms 

um indicate the surgical procedures THR and TKR.

We have added some of our specific terms, and the entire search strategy is in Appendix A.

 to have a discrepancy in the number of articles categorized in the bottom row 

58 studies categorized in the bottom row. The row above indicates there were 

s there are 11 articles (69 minus 58 = 11) that are not categorized. 

Additional explanations have been added to clarify the overlapping nature of the categories, which accounts for the numerical discrepancy.

to provide a breakdown of which or how many articles addressed racial 

ssed gender disparities. The current breakdown seems to indicate only 1 

ties

This is correct, there was only one gender article. 

numbers. It says 69 articles were assessed but the numbers below don’t 

so, I think it would help the reader to explain the literature groups below the 

Additional explanations have been added to clarify the overlapping nature of the categories, and the groups are now referred to by key question, rather than generation, for clarity.

was not used as inclusion/exclusion criterion. However, Figure 3 includes 

rejection criterion.

We have reworded the figure to be more specific.

Question #2 is related to a comparison of VA and non-VA county hospitals. It 

f there is a clear statement about how these data relate to the key questions 

system-level factor?).

Updates have been made to address this.
41

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

Comment Response

VA Data, 3rd sentence – it is not completely clear what the comparison is for 

issue in the sentence.

This sentence has been updated.

ed to – is the 2nd paragraph in this section about the third study? Yes, this has been noted in the text.

ICD-9 codes were used? ICD-9 codes have been added where necessary

on-VA data: some discussion of the magnitude of differences in TKR rates 

The Kane review (published in arthritis care and research), does not list actual rates of use, just that rates in one group are larger or smaller than others. We think that the rates presented in the following studies below can present a sense of magnitude of differences in rates.

– doesn’t fully summarize the results (or lack thereof) regarding patient, 

rs. 

Changes have been made.

 cohort is being referred to, in other places it is less clear (e.g., “another VA 

Throughout, it would be helpful to have a consistent way of referring to each 

Updates have been made to better identify the cohort (e.g. the Cleveland cohort)

formation under Non-VA Data that starts on p21 is needed. It seems a bit out 

This section has been updated for better flow.

would be helpful to compare / contrast this with VA data, mentioning any 

n which there are may be more data for non-VA vs. VA.

Updates have been made to address this.

 of findings’ section at the end that includes both VA and non-VA data. 

nd was confusing at first – that is, within the KQ2 sections there are three 

VA + non-VA, VA, and non-VA.

This structure was used due to the volume of literature in the sections.

ing gender disparities in the VA. This finding of limited research related to 

summary of findings. 

The summary has been updated to reflect this.

 under VA data---I think you want a “the” before VA. Also, in the 2nd

ma rather than a period in the pt estimate of 0.3 %

Changes have been made.

f first sentence. Note also that the last sentence of this paragraph does not 

dds are of????

This sentence has been removed.

tence of 2nd paragraph Edits have been made to address this issue.

ast sentence-----I think you mean TJR rather than OA OA has been verified.

ut “thus” Fixed

ew the middle sentence that states “social support between various racial 

acture.....

This sentence has been reworded for grammar and clarity.

ut KQ 3 since there seemed to be little good evidence about disparities in the 

he limitations of the VA data on disparities as you discuss an intervention to 

Noted
42

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

Comment Response

ce the word “joint” probably doesn’t belong there or you need to add TJR Sentence has been verified.

u are talking about the disparities, even if the data are not robust, I think you 

nd in terms of the disparities. Also, I thought some of the differences were 

onfounders? This is a good place to reiterate that.

This is discussed in the “clinical need” paragraph. The differences may decrease after adjustment, but they don’t go away entirely.

oing to talk about the one published study it makes sense to me to summarize 

This has been added.

 Research

more specific recommendations at the end of the review, arising from the 

nstance: 1) areas with conflicting findings; 2) areas needed to be studied in 

mation is available (e.g. women are mentioned, how about Hispanics); and 3) 

uld be evaluated on the basis of the findings – patient-based or QI.

We have revised the future research section

nd detailed review of the literature, and it would be very helpful if more 

d be drafted in summary of the review. There may also be recommendations 

 to implementation, but given the current state of the research, it seems 

ed regarding interventions to address disparities, before these are put into 

help readers / stakeholders to get more out of the evidence synthesis if a more 

s provided with respect to what is still needed. 

We have revised the future research section

ything to implement. The call for more research seems appropriate We have revised the future research section

commendations for further research. it seems to me that if the evidence base 

eneration disparity studies that these should be conducted prior to suggesting 

it is not completely clear to me that there are disparities at the VA. I would 

(it can be short) in this paper with some discussion of the problems with this 

am struck by how often point estimates of disparity were either reduced or 

founders. I think this deserves more synthesis and discussion.

We have revised the future research section

 is 57? The number does not match up with the numbers in Figure 3 Numbers have been updated.
43

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

vidence Tables

Evidence Table

Type; 

e 

on; 

nse Rate/ 

 Up

Total pop; VA pop*

Data Source Gender, 

Race**/ How determined

Joint Discussed***

Outcomes Results

t/ Case

l;

ar; 

ecified

457; 457 VA, multiinstitution W/ SelfReported TKR, THR recommenda- tion for procedure;

receipt of procedure

Lower odds of receiving a TJR recommendation for B than W of similar age and disease severity (OR 0.46, [95% CI 0.26–0.83]; P=0.01). Difference was not significant adjusting for patient preference for TJR (OR 0.69, [95% CI 0.36–1.31], P=0.25).TJR less likely for B than W of similar age and disease severity (OR 0.41 [95% CI 0.16–1.0], P=0.06); difference reduced adjusting for recommendation for procedure at the index visit (OR 0.57 [95% CI 0.21–1.54], P=0.27).

nal; 

ased; 

329,461;329,461

VA National Women/ 

Admin

TKR, THR Adjusted odds 

of getting TJR

Among patients with OA, men and women in the VA were equally likely to undergo TKR (153 [1.6%] women and 4,638 [1.5%]) men and THR (73 [.8%] women and 2147 [.7%] men). Receipt of surgery within 2 years for women with OA versus men was not significant (TKR: OR 0.96 [95% CI 0.82 to 1.13]) and (THR: OR 0.99 [95% CI 0.79 to 1.26]).

t/ Case

l;

ased; 

ecified

260856; 260856

VA National W, B/

Admin. data

TKR receipt of 

procedure

B were less likely than W to have received TKA within 2 years (OR 0.72, [95% CI 0.65–0.80] in OA cohort and OR 0.72, [95%CI 0.63–0.81] in specialty clinic subcohort.

nal; 

ased;

2.9 million; 0

Medigap % non-white 

by zip code/Admin

Hip or knee replacement

receipt of procedure

Patients living in high-minority areas were 20% less likely to undergo a hip or knee replacement as low minority areas.

nal; 

ased;

8000000 NIS W, B, H, A/

Admin

TKR, THR receipt of 

procedure

Non-whites had lower odds of THA and TKA compared with whites. Minorities were 23% to 64% less likely to undergo arthroplasties. Racial disparities were larger than income disparities and not confined to elderly or low-income.
44

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

Type; 

e 

on; 

nse Rate/ 

 Up

Total pop; VA pop*

Data Source Gender, 

Race**/ How determined

Joint Discussed***

Outcomes Results

nal; 

ased;

46000000; 0

Medicare, NIS

W, B, H, A/Admin. data

TKR, THR receipt of 

procedure

Compared with urban beneficiaries, rural were more likely to have TJR (OR 1.27 [95% CI 1.26– 1.28]). Adjusting for age, sex, race/ethnicity, income, poverty ratio, and state, rural beneficiaries were still 14% more likely to have TJR (OR 1.14 [95% CI 1.13–1.16]).

nal; 

ased;

26000000; N/A

Medicare W, B/

Admin. data

TKR receipt of 

procedure

From 2000 to 2006, TKR rate in the US increased 58%, from 5.5 to 8.7 per 1,000, with similar increases among W (61%) and B (56%). Rate of TKR for B was 37% lower than W in 2000 (3.6 versus 5.7 per 1,000) and 39% lower in 2006 (5.6 versus 9.2 per 1,000).

nal; 

ased;

71418; NR National, 

HCUP

W, B, H/Admin. data

THR receipt of 

procedure

No difference in the likelihood of THR between B, W and H for 1997 or 2000, after adjusting for income, urban/rural, distance from hospital, and social isolation, but not severity of arthritis. 

t/ Case

l; 

ased;

ecified

14807; NR Health and 

retirement study, national

W, B/Self-reported

TKR, THR need for 

surgery; receipt of procedure

Lower receipt of TJR in B (vs W: OR 0.47; CI 0.26–0.83) or less educated (0.65; 0.44–0.96). Differences not explained by employment, access, family responsibilities, disability, living alone, comorbidity, or excluding younger than Medicare.

t/ Case

l; 

ased;

ecified

18439; NR National W, B, H/

Self-reported

TKR receipt of 

procedure

B men (relative to W women) were less likely (OR 0.46 (0.28–0.78), [P < 0.05]) to receive TKA. Adjusting for economic factors, racial/ethnicity, TKA rates differences for women disappeared, while remaining large for B men (OR 0.56 [0.33–0.95]).

nal; 

ased;

27494659; NR

NHANES, national Medicare

W, B, H, A/Admin. data

TKR receipt of 

procedure; Prevalence of OA

Relative to W men, B men were less likely to undergo TKA (OR 0.36 [95% CI 0.34 to 0.38); as were H men (OR 0.67 [0.62 to 0.73]; Asian men (OR 0.28 [0.24 to 0.32]; and Asian women (OR 0.45 [0.41 to 0.49]. W women were more likely (OR 1.34 [1.33 to 1.36]). [No income gradient for clinical and radiographic measures of arthritis, except a negative association of income and pain on passive motion (P<.05).]
45

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

Type; 

e 

on; 

nse Rate/ 

 Up

Total pop; VA pop*

Data Source Gender, 

Race**/ How determined

Joint Discussed***

Outcomes Results

nal;

ased;

443008; NR

NIS, national W, B, H/

Admin. data

TKR receipt of 

procedure

In 1998-2000 as compared to 1990-1993, B and Hispanic patients were more likely to undergo TKA (OR 1.6 [95% CI 1.5–1.6] and OR 2.7, [95% CI 2.5–2.9],respectively). However, W patients accounted for 87.5% and 93.0% of TKAs, in the 2 time periods.

nal;

ased;

29000000; NR

Medicare Non-B/

Admin. data

THR receipt of 

procedure

Rates of TKR and THR among the Medicare fee for service population were compared from 1992 to 2001. 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 to 1.85 for black men. Among women, rates of TKR per 1000 population were 6.6 among nonblacks and 5.1 among blacks.

nal; 

ased; 

67,475; NR Regional 

(Wisconsin Hospital Discharges)

Gender/ Admin. data

TKR receipt of 

procedure

In both 1990 and 2000, women had higher rates of TKR. Rates of TKR per 100,000 in 1990 were 30 for women compared to 23 in men, and in 2000 were 46 in women compared to 35 in men.

nal;

ased;

Many; NR Regional W, B, H/

Admin. data

TKR receipt of 

procedure

Connecticut hospital data (1996-1998) found that 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 men 66.5 (63.9 -68.9).

nal;

ased;

403251; 0 National, 

Medicare

W, B, H/Admin. data

TKR receipt of 

procedure

Rate of TKA was higher for W women (5.97 procedures per 1000) than for H women (5.37 per 1000) and B women (4.84 per 1000). Rate for W men (4.82 procedures per 1000) was higher than H men (3.46 per 1000) and more than double that for B men (1.84 per 1000). The rates were lower for B men in nearly every region of the country (P<0.05). [For H population and for B women, racial/ethnic disparities were due in part to geographic differences rather than to differences in the rates for racial and ethnic groups within geographic areas. Residential segregation and low income levels contributed to disparities.]
46

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

Type; 

e 

on; 

nse Rate/ 

 Up

Total pop; VA pop*

Data Source Gender, 

Race**/ How determined

Joint Discussed***

Outcomes Results

nal;

ased;

19311; 0 Medicare in 

NM, IL, TX, AZ

W, B, H, A/Two or more sources

THR receipt of 

procedure

1% THR recipients and 3.3% controls were H (P<.001). Odds of THR decreased as probability of H ethnicity increased (OR 1.00 non-H surnames to OR 0.36 H surnames (95% CI, 0.31, 0.43). Poverty did not modify the low odds of THR among H (OR, 0.25 Medicaideligible Hispanic persons; 95% CI, 0.19, 0.33; and OR, 0.30 Hispanic persons not Medicaid eligible; 95% CI, 0.24, 0.38).

nal;

754; 0 Regional W, A/

Medical record review

THR receipt of 

procedure

THR for W was three to 25 times greater than that of Japanese, Chinese, Filipino, and Hawaiians. Risk of THR for W women was 4.4%, compared with 1.1% for Japanese women and 1.7% for Chinese women. For white men, the incidence rate is 3.6%, which is 4.5 to nine times greater than the rate for other ethnic groups. Some between region differences were noted (Hawaii versus San Francisco).

nal;

ased;

6586; NR OSHPD, 

regional

W, B, H, A/NR

THR receipt of 

procedure

Asians had higher odds of THR (OR 2.13 [95% CI 1.3-3.45]) than W. W had higher, but non-significant, odds of THR than H (OR 1.32 [.87-1.96]) and than B (OR 1.56 [.97-2.50]).

nal;

ased;

414079; 0 Medicare, 

national

W, B/Two or more sources

TKR receipt of 

procedure

Odds of W receiving TKR were 1.5 times greater than for B. Adjusting for demographic factors, regional variation remained. TKR were over two and one-half times more likely for B women than for men (OR 1.66); the difference was only 24 percent for W women versus W men (OR = 1.24). Procedures were performed on W men much more often than on B, (OR 2.50). Difference between W and B women was much smaller (OR = 1.16).

nal;

ased;

1589; 0 San 

Francisco

W, B, H, A/Medical record review

THR receipt of 

procedure

The greatest annual rate of THR occurred in W women (97 per 100 000), followed by W men, B women, B men, H women, and H men. Smallest numbers were found in Asians, rate was 10% of W. Age standardized THR rates for primary coxarthrosis per 100 000 were greatest among W (43.0) and least among Asians (1.3 for Chinese). Mean age undergoing THR for primary coxarthrosis was 70 years for W and a decade younger in other groups.
47

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

Type; 

e 

on; 

nse Rate/ 

 Up

Total pop; VA pop*

Data Source Gender, 

Race**/ How determined

Joint Discussed***

Outcomes Results

nal;

ased; 

a lot; 0 Medicare, 

national

W, B/Admin. data

TKR, THR receipt of 

procedure

TKR increased from 1986 and 1992, 98% among white beneficiaries and 121 percent among blacks. In 1992, the rate in blacks was 64% as great as for whites.

nal;

ased;

over 3000; NR

NHANES, Medicare

W, B/Admin. data

TKR receipt of 

procedure; Rate of OA

B were less often treated with TKR than W (men: OR=3.16 [1.69-5.91]; women: OR=1.55 [1.00-2.41]) for age 65-69.

nal; 

ased;

1204022; 0 Medicare, 

national

W, B/Admin. data

TKR, THR receipt of 

procedure

W are two-fold more likely to undergo THR (RR 2.36 [1.92, 2.89]) or TKR (RR 2.02 [1.63, 2.49]) than blacks.
48

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

Evidence Table

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

on-VA Studies

/ Case

nience;

676; 388 Single VA W, B/

Selfreported

TKR, THR Appropriateness, 

benefits, barriers, OA severity, length of time to referral; outcome expectations of surgery, perceived risk

Clinical appropriateness (HR 1.95, [95% CI] 1.15–3.32; P <0.01) predicted referral to orthopedic surgery. Neither race (HR 1.30, 95% CI 0.94–2.05; P =0.1) nor health beliefs (HR 1.0, P = 0.5) were associated with referral status. 

al; 

nience;

8

685; 388 Single VA W, B/

Selfreported

TKR, THR Appropriateness 

for procedure

There were no significant racial group differences (p = 0.3) in the proportions of those deemed clinically appropriate for TJR. Controlling for confounders (BMI, SES, education, county vs VA), race was not a predictor of clinical appropriateness for TJR (odds ratio 1.2, 95% CI [0.8–1.8], P =0.3).

al;

nience

691; 390 Single VA W, B/

Selfreported

TJR Benefits, barriers, 

OA severity, arthritis health, belief scale

B perceived less benefit from TJR than W (58.1 vs 44.3%; P=0.0001; OR=.60 (.42–.86), P=.005; B more likely to perceive barriers 42.4 vs 30.8%; P=.002; OR=.60, [CI] .42- .86, P=.005); Race not predictive of perceived severity of OA OR=.97 (.62–1.53), P=.9

/

ontrol; 

r; Not 

ed

409; 409 VA W, B/Selfreported TKR, THR Patient-provider communication Visits with B, compared with W, contained less discussion of biomedical topics (B=-9.14, 95% 

CI -16.73 - -1.54) and more rapport-building statements (B-7.84; 95% CI 1.85- 13.82. No racial differences in length of visit, overall amount of dialogue, patient activation/engagement statements, discussions of psychosocial issues, physician verbal dominance, displays of positive affect, or evidence of informed decision making.
49

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

/ Case

r;

cified

457; 457 VA W, B/

Selfreported

TKR, THR recommendation 

for procedure; receipt of procedure

Lower odds of receiving a TJR recommendation for B than W of similar age and disease severity (OR 0.46, [95% CI 0.26–0.83]; P=0.01). Difference was not significant adjusting for patient preference for TJR (OR 0.69, [95% CI 0.36–1.31], P=0.25).TJR less likely for B than W of similar age and disease severity (OR 0.41 [95% CI 0.16–1.0], P=0.06); difference reduced adjusting for recommendation for procedure at the index visit (OR 0.57 [95% CI 0.21–1.54], P=0.27).

al;

nience;

939; 939 VA W, B/

Selfreported

TKR, THR prayer for pain, 

coping strategies, self efficacy

B more likely to perceive prayer helpful (OR 3.38, 95% CI [2.35 to 4.86]) and use prayer (OR 2.28, 95% [1.66 to 3.13]) to treat osteoarthritis pain as compared to W. B more likely to use coping and praying (β=0.74, 95% CI [0.50 to 0.99]).

al;

nience;

909; 909 VA W, B/ Selfreported TKR, THR outcome expectations of 

surgery

B knee OA patients have lower expectation score (scale 0-76) than W even with adjustment for disease severity, SES, social support, literacy and trust (difference -3.8 points [95% CI 1.2, 6.3], and 4.2 points (95% CI 0.4, 8.0) among hip patients.

mental;

nience;

cified

64; 64 VA W, B/ Selfreported TKR outcome expecta- tions of surgery, 

willingness to consider surgery, knowledge of surgery, alternative treatment

B had lower (but not significant) expectations for TKR than W for pain (WOMAC score 41 versus 34; P=0.18) and physical function (WOMAC score 38 versus 30; P = 0.13). B were less likely to have heard of TKR (49% versus 72%; P =0.02) and less likely to know someone who had TKR (34% versus 53%; P =0.05) than W.

/ Case

sed;

18811; 18811

NSQIP, VA W, B, H/ 

Admin. data

TKR, THR complications Rates of non–infection and infection-related 

complications after TKA were higher among B compared with W (RR 1.50, [95% CI 1.08–2.10] and RR 1.42, [95% CI 1.06–1.90]). H had a higher risk of infection-related complications (RR 1.64, 95% CI 1.08–2.49) relative to W. Race/ethnicity was not associated with the risk of non–infection-related or infection-related complications for THR. 30-day mortality was 0.6% following TKA and 0.7% following THR, with no race/ ethnicity differences
50

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

al;

nience;

0

596; 596 VA W, B/

Selfreported

TKR, THR participant/

provider relationship, perception access to care, receipt of referral

B were less likely than W to report difficulty getting medical care (OR 0.54 [0.34-0.88]). B were less likely than W to perceive the patientphysician relationship as excellent (24.7% vs. 36.3%, P<0.0 1) and less likely to have confidence in their primary physician (75.7% vs. 82.6%, P=0.04). Difficulty accessing care outside VA was not different between groups (52.4% vs. 52.2%, P=0.95).

al;

nience;

to 

up

558; 558 VA W, B/ Selfreported TKR, THR perception of symptoms B and W were not different in mean scores for WOMAC pain and WOMAC function when 

stratified by joint space narrowing, osteophyte and Kellgren Lawrence grades. After controlling for important covariates, ethnicity was not a significant predictor of WOMAC pain and function.

al;

nience;

cified

300; 300 VA W, B/ Selfreported TKR, THR Perception of pain B and W patients describe the quality of their chronic knee and hip pain differently. Chronic pain quality 

descriptions correlate with western Ontario and McMaster Universities Arthritis Index Scores but not radiologic stage of disease. {factor analyses}

al;

nience;

6

596; 596 VA W, B/ Selfreported TKR, THR willingness to consider surgery, 

outcome expectations of surgery, familiarity with surgery

B were less likely than W to be willing to consider surgery for severe arthritis (OR 0.53, [95% CI 0.30-0.96]. After adjustment for outcome expectations, the difference between races in willingness to consider was not significant (OR 0.86, [95% CI 0.45-1.63]).

al;

nience;

596; 596 VA W, B/ Selfreported TKR, THR Role of prayer in the management 

of arthritis, willingness to consider surgery

B less willing than W to consider surgery for severe hip or knee arthritis pain (OR .059, [95% CI 0.34-0.99]). B more likely than W to perceive prayer as helpful in managing their arthritis (OR 2.1; [95% CI, 1.19, 3.72]).

al;

nience;

6

596; 596 VA W, B/ Selfreported TKR, THR QOL For patients with chronic joint disease, B less likely than W to rate quality of life as excellent or 

very good. Difference persisted after adjusting for demographic, clinical, and psychosocial covariates, and severity of osteoarthritis (B=-0.121, P=.004).
51

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

al;

nience;

6

596; 596 VA W, B/ Selfreported TKR, THR outcome expectations 

of surgery, knowledge of joint replacement

B were less likely than W to have family/friends that had TJR (OR 0.39 [.26-.61]) or a good understanding of TRJ (OR 0.62 [.42-.92]). B more likely to expect longer hospital course (OR 4.09 [2.57-6.54]), moderate to extreme pain (OR 2.61 [1.74-3.89]), moderate to extreme difficulty walking after joint replacement (OR 2.76 [1.83-4.16]).

al;

nience;

6

593; 593 VA W, B/

Selfreported

joint replacement

efficacy arthritis treatment

B were more likely than W to perceive TJR as efficacious (OR .52 [.28-.98]) and more likely to rely on self-care measures for their arthritis (OTC meds: OR 1.76 [1.14-2.72]); friend/family advice: OR 2.11 [1.44-3.07]); decrease activities: OR 2.22 [1.28-3.85]); apply med cream: OR 2.27 (1.38-3.73]). Use of prayer more likely to be perceived as efficacious in B (OR 1.93 [1.19-3.14]).

/ 

ontrol; 

utive 

s;

cified

185; N/A Single 

institution

B, Non-B/Medical Record Review

TKR outcome of 

procedure, outcome expectations of surgery

B men had longer delays to presentation than non B men (29.9 months [CI 17.2, 42.6] vs 20.0 months [CI 4.4, 35.6]) and worse 2-year KSS (89.6 months [CI 85.0, 94.2] vs 94.1 months [CI 91.2, 97.0]). B women had worse final ROM and similar final gains in ROM (postoperative minus preoperative) controlling for confounders.

ectional;

utive 

;

cified

3542; 0 Single 

institution

W, B, H/Selfreported

TKR, THR preop jt function Lower function with Harris Hip Scores 4.9 (P< 

.0001) and 8.77 (P<.001) and Knee Society Scores that were 6.03 (P<.06) and 12.8 (P<.001) points lower in B and H patients than W.

tive;

r;

cified

37, 0 Single 

institution

W, B, H/ Selfreported

TKR willingness to 

consider surgery, outcome expectations of surgery, TKR Knowledge, Current prob knee OA

Attitudes and beliefs of surgical decision-making were primarily based on personal experiences. Personal experiences had both positive or negative impacts and included concerns about outcomes following surgery and possible complications. B did not have more concerns or fewer expectations.
52

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

al;sed;

cified

25598, 0 NYC 

discharge data

W, B, H, A/Admin. data

THR use HVH 

(hospital), use HVH (surgeon)receipt of procedure

B, Asians, H were more likely to be operated for TJR in low volume hospitals by low volume surgeons than whites (25.3%, 35.0%, 23.0% and 15.6%; P<.001)

/ Case

nience;

cified

331; 0 Single 

institution

W, B/Selfreported

TKR, THR outcome of 

procedure, fear of surgery, physical function

B patients had greater fear before joint arthroplasty compared with W. After surgery, B had higher fear subscale, cognitive subscale, and total PASS score (WOMAC physical function, pain, and total scores.

/ Case

sed;

69793; NR

National W, B, H, A/

Admin. data

THR outcome of 

procedure

B and H had higher odds of discharge to home following hip replacement (B: OR 1.23 [1.107-1.41] and H: OR 1.5 [1.15-1.99]). B not significant. Men had higher odds of discharge to home (OR 1.18 [1.01-1.17]). Mean functional status change not predictive of discharge disposition (OR 1.10 [1.10-1.11])

/ Case

sed;

cified

14807; NR

National W, B/

Selfreported

TKR, THR need for surgery, 

receipt of procedure

Lower receipt of TJR in B (vs W: OR 0.47; CI 0.26–0.83) or less educated (0.65; 0.44–0.96). Differences not explained by employment, access, family responsibilities, disability, living alone, comorbidity, or excluding younger than Medicare.

/ Case

sed;

cified

18439; NR

National W, B, H/

Selfreported

TKR receipt of 

procedure

B men (relative to W women) were less likely (OR 0.46 (0.28–0.78), [P < 0.05]) to receive TKA. Adjusting for economic factors, racial/ethnicity, TKA rates differences for women disappeared, while remaining large for B men (OR 0.56 [0.33–0.95]).

tive;

nience;

cified

37; NR Single 

institution

W, B, H/Selfreported

TKR attitudes and 

beliefs about TKR

Knee OA is experienced differently by ethnicity and groups, and perceptions of the cause of knee OA vary. Trust is important for H considering TKA. Economic factors do not constrain the decision to have surgery.
53

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

al;sed;

138399; NR

OSHDD (California input database)

W, B, H, A/Admin. data

THR receipt by 

hospital volume

H had higher RRR [3.52 (95% [CI], 2.61-4.74; p < .001)] for the use of a low-volume hospital when compared to W. B (RRR, 1.78; p = .023) and Asian patients (RRR, 1.77; p = .048) also had a higher RRR compared to W for the use of low-volume hospitals

al;sed;

1E+05; NR

OSHDD (California input database)

W, B, H, A/Admin. data

TKR receipt by 

hospital volume

B, Asians, and H were more likely to have TKR at low volume hospital than W (RR=1.32 [95% CI 1.25-1.39], RR=1.72 [95% CI 1.60-1.81], RR=1.64 [95% CI 1.58-1.69])

al;

m digit 

cified

391; NR Single 

institution

W, B, H/Selfreported

TKR willingness to 

consider surgery

B less likely to chose surgery than W (OR 0.63 [CI 0.42, 0.93]). Women and older patients were also less likely to choose surgery (OR 0.69 [0.51, 0.94], OR 0.98 [0.97, 0.99]). Larger reductions in negative symptoms with surgery increased the likelihood of choosing surgery. No difference between the public and patients, and no effect of income level was noted.

al;sed;

198; 0 Single 

institution

W, B, H/Selfreported

TKR recommendation 

for procedure, willingness to consider surgery, outcome expectations of surgery, preferences for surgery, familiarity of surgery

Physician more likely to discuss TKR with B (27%), 15% W, 11% H (P=.04). More W than minorities (B and H combined) considered TKR (42% vs 28%; P=.04). No differences between B, H, W being familiar with TKR.

al;

nience; 

4

94; 0 Harlem B/

Selfreported

TKR outcome 

expectations of surgery

In B with high rate of severe OA (mean QoL7.6 ±1.7), few (36%) believed TKR would improve knee pain; and 45% felt surgery would not improve their health. 

al;sed;

193; 0 Harris 

County

W, B, H/Selfreported

TKR willingness to 

pay

Willingness to pay (WTP) as a percentage of income was lowest for B (16.7% for mildOA) as compared to 32.9% W, 26.4% H. Controlling for income, differences in WTP between B and W were significant in multivariate regression analyses, whereas values for H and W were not.
54

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

tive;

nience;

cified

94; 0 Harlem B/

Selfreported

TKR outcome 

expectations of surgery, briefs and goals surgery, pref stay in current state, relationship w specialist

Content analyses identified 6 themes: preference for natural remedies, negative expectations of surgery, beliefs about God’s control, preference for continuing in their current state, relationships with specialists, and fear of surgery or death.

tive;utive;

37; 0 Single 

institution

W, B/Selfreported

TKR concern about 

surgery

B women asked the most questions about criteria for TKR; W women asked about drawbacks from surgery; W men asked about devices; B men asked about financial issues and insurance coverage. Only W asked about intraoperative issues. W women asked about recuperation, functional recovery and pain, B women asked about longterm outcomes and support after surgery. W men asked about QOL and B men asked no questions. W men had greatest factual knowledge about surgery.

al;sed;

12328; NR

4DSMR, national

W, B, H, A/Two or more sources

TKR, THR outcome of 

procedure

W and B were (P <0.05) more likely to be discharged home alone and responsible for their own care than Asian or H. 36% H after THA or TKA received inpatient medical rehabilitation 58% W, 67% B, and 56% Asians.

al;sed;

970; 0 Medicare 

Manhattan

W, B/Two or more sources

hip/knee surgery

Social network, Perception of benefit of arthritis treatment

42% B compared 65% W reported knowing someone who had surgery for hip or knee pain (P<.0001). B less likely that W to report that surgery had helped someone they knew with hip or knee pain (but not significant). B more likely to have sought care in ER/clinic 22% vs 9%, P<.005) and less likely to have seen an orthopedic surgeon 3% vs 15%, P<.0001). No racial differences in use of self-treatments (OTC, herbs PT, health/cold)
55

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

ype; 

 

n; 

se Rate/ 

Up

Total pop; VA pop*

Data Source Gender/

Race**/ How determined

Joint Discussed***

Outcomes Results

al;sed;

over 3000; NR

NHANES, Medicare

W, B/Admin. data

TKR receipt of 

procedure, Rate of OA

Prevalence of symptomatic OA knee was lower (but not significant) in W compared to B (men OR .39 [.13-1.14] and women OR .78 [.34-1.80]). Racial differences in TKR were consistent across income levels and were unexplained by B having operations at an earlier age or using competing procedures.

Evidence Table

Type Total 

pop; VA pop*

Data Source Race**/ How 

determined

Joint Discussed***

Outcomes Results

mental;

ience;

cified

64; 64 VA W,B/

Self-reported

TKR Willingness 

to consider surgery, outcome expectations of surgery willingness to consider surgery, knowledge of surgery, alternative treatment

At baseline, 13% W and 29% B were willing to consider surgery (P <0.12); after intervention, 13% W and 33% B were willing to consider surgery (P <0.06).

anic; A=Asian

t; THR=Total Hip Replacement