Orthopedic communication about osteoarthritis treatment: Does patient race matter?

There are large and well-documented racial disparities in the use of total joint replacement (TJR) as a treatment for advanced knee and hip osteoarthritis.1-9 In particular, African American patients are significantly less likely than white patients to undergo knee or hip TJR.7, 10-12 Reasons for these disparities remain unclear, although research suggests they are not explained by differences in healthcare access or clinical need.8, 13-15 Patient preference may play a role, as studies have shown that African American patients are less willing than white patients to consider TJR as a treatment option for knee/hip osteoarthritis.16-19 What has not been well-studied as a contributing factor to racial disparities in TJR is the role of patient-provider communication regarding the management of knee/hip osteoarthritis in the orthopedic setting. Because osteoarthritis is progressive and incurable, the goals of treatment are to alleviate pain, improve function, and limit disability.20 Non-surgical treatments such as physical therapy or analgesic medications can be effective for moderate cases, but TJR is often the most appropriate and effective treatment for severe cases.21, 22 TJR is an elective and preference-sensitive procedure, however, as there are no established criteria indicating the need for TJR based on absolute levels of pain or disability. Patient-provider communication about osteoarthritis treatment options in the orthopedic setting is therefore likely to play a prominent role in the decision-making process about TJR. Examining whether racial differences occur in orthopedic discussions of osteoarthritis management is important given that racial variation in patient-provider communication has been documented in other healthcare settings. For instance, in primary care, visits with African American (vs. white) patients have been found to be more narrowly focused on biomedical issues23, less patient-centered, more dominated by physicians, and less positive (i.e., patients and physicians display less positive affect).24 Studies of patients with particular medical conditions (e.g., HIV25, lung cancer26, breast cancer27, depression28) have also found that African American patients tend to talk less than white patients in general or engage less in specific kinds of communication, such as rapport-building. Less research has examined racial differences in patient-provider communication in the orthopedic setting. In one analysis of orthopedic consultations among patients with a variety of conditions, Levinson and colleagues found that informational content of communication did not differ substantially by patient race, but visits with African American patients contained less relationship-building communication (i.e., responsiveness, respect, and listening) than visits with white patients.29 The current study examined whether there were racial differences in patient-provider communication in a sample of white and African American patients referred to orthopedic clinics specifically for the treatment of advanced knee or hip osteoarthritis. To provide a comprehensive analysis of communication, we coded patient-provider interactions using two methods. The Roter Interaction Analysis System (RIAS)30, 31 was used to examine the types of statements made by providers and patients (i.e., biomedical, psychosocial, rapport-building, or patient-activation), the provider-to-patient ratio of communication (i.e., physician verbal dominance), and the display of positive affect by patients and providers. The extent to which providers invited patients to participate in decision-making about treatment options was further assessed using the Informed Decision Making (IDM) Model.32, 33 IDM, which refers to thoughtful dialogue between a healthcare provider and a patient that leads to a clinical decision, exemplifies patient-centered care.32 IDM requires the discussion of technical aspects of a decision (e.g., nature of decision, alternatives, risks) as well as the assessment of patient understanding and preferences.32 We hypothesized that the previously discussed racial differences in patient-provider communication observed in other patient populations23-29 would be observed in our sample.