Studies have shown that racial minorities in the United States undergo fewer total knee replacements (TKR) for knee osteoarthritis (OA) than whites do, but the reasons for this are unclear. A new study sheds light on why fewer black Americans tend to have the surgery – and at what cost. It found that African-Americans are offered the option of TKR in fewer cases than whites are, they accept the option less frequently, and when they do undergo the procedure, they have higher rates of complications. Because of these factors, they lose a large number of what’s called “quality-adjusted life years” or QALYs.
What’s a QALY?
“Severe knee OA is a debilitating disease that affects people’s functional ability to participate in and enjoy everyday life,” explains senior study author Elena Losina, PhD, co-director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham & Women’s Hospital, in Boston. “TKR is a successful surgery that can greatly reduce pain and improve the ability to take part in activities of daily living – walk, go shopping, participate in social events and travel. Such differences in quality of life can be accumulated across many years.”
“Black Americans with advanced knee OA are less frequently offered TKR [by their physicians] and thus they continue to live with functional limitations that reduce their quality of life for many years,” says Losina. “Increasing the offer of TKR to black Americans with severe knee OA could improve the lives of many people over many years.” That’s the idea behind the term QALY.
This research is important, says Losina, because “it is the first study that translates the disparity in use of TKR between blacks and whites into language of public health relevance. The bottom line is that underutilization of the highly successful surgery leads to drastic losses in quality-adjusted life years [QALYs] among black Americans,” she states.
The researchers calculated that African-Americans who receive knee replacements currently gain 64,100 QALYs (across the population). If they were offered and accepted surgery at the rate whites do, and if their complication rates were as low, they would gain an additional 72,000 QALYs – or more than double what they currently gain.
The largest proportion of lost QALYs comes as a result of lower offer rates. The study authors, therefore, suggest that health professionals improve their attempts to offer TKR to black Americans who have advanced knee OA.
What Can Patients Do?
Losina also suggests providing more and better information for African-Americans about advanced knee OA so that they are more willing to take advantage of the surgery and to share in the decisions with their doctors. People who have knee OA should discuss their concerns about TKR and the surgery’s overall risks and benefits with their doctors.
“Patients should take some responsibility for asking questions,” Losina says. “At the end of the day, TKR is an elective procedure – that is, it is the patient’s choice, and the decision to have it should be in the patient’s hands,” Losina says.
Rowland Chang, MD, an expert in the outcomes of orthopedic surgical treatments for arthritis and a professor at Northwestern University Feinberg School of Medicine, in Chicago, believes that African-Americans with advanced knee OA should seek TKR (if they are good candidates), despite the documented higher complication rates and worse outcomes. “Forgoing TKR when one is severely functionally limited by knee pain due to advanced OA will only lead to further increases in pain and functional limitation,” says Dr. Chang, who is also the Arthritis Foundation’s chair of the board of directors.
“Patients should speak to their doctors with the key request that they be referred to a surgeon who specializes in TKR surgery and performs them in a high-volume TKR hospital,” Dr. Chang says. It’s likely that black Americans have worse outcomes because a smaller proportion of their knee replacement surgeries are done at high-volume hospitals, which have lower rates of complications, he says. In addition, African-American patients on average wait longer than other patients to have the procedure, which makes it more challenging surgically and for improvements in pain and function.
Author: Alice Goodman
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