While about a million people get knee replacements in the United States each year, significant number of patients who need the surgeries do not receive them, particularly African Americans, according to Said Ibrahim, MD, MBA, the featured speaker at the April 24 University of Pennsylvania annual memorial lecture honoring the late Charles C. Leighton.

A former Penn professor and LDI Senior Fellow, Ibrahim is currently Dean of the Medical College at Thomas Jefferson University and a nationally recognized physician-scientist whose work focuses on health care disparities, particularly in musculoskeletal disease and access to surgical care. He is also the former Chief of Medicine at Philadelphia’s Corporal Michael J. Crescenz VA Medical Center and Director of the VA Center for Healthcare Evaluation, Research, and Promotion (CHERP) there.

Over the past three decades, his research has documented marked differences in the utilization of joint replacement. For instance, minority patients such as African Americans are about 30% to 40% less likely than to undergo knee replacements despite having similarly severe osteoarthritis of the joint. His subsequent research identified patient preferences, and communication barriers as key drivers of these disparities. A third phase of research showed that educational interventions could increase surgery rates for African American patients who are candidates for knee replacement surgery. His current work examines systemic policy changes, including how mandatory bundled payment models may affect surgical care inequities.

“Complicated Health System”

“We have a very complicated health system that can differ depending on socioeconomic background,” Ibrahim told the audience in Penn’s Biomedical Research Building. “One dimension of that complexity is that we are still struggling to ensure that every person has access to health care.”

“Osteoarthritis of the knee and hip is one of the most prevalent forms of arthritis. It typically begins around age 50, and the likelihood increases with age. There is no cure, but when the disease becomes severe, surgery is an effective option for appropriate patients. It is one of the safest elective surgeries we perform,” he said. “However, there are marked differences in access to this surgery. It varies by gender. Although arthritis is more prevalent in women, women who need knee or hip replacement are less likely than men to receive it. It also varies geographically. Patients in the Midwest are more likely to receive surgery than those on the East or West coasts.”

Race and Ethnicity Disparities

“As noted earlier,” he continued, “one of the most significant disparities involves race and ethnicity. Our team sought to understand why, when a condition is equally prevalent and treatment is clearly indicated, its use still varies by race.”

Ibrahim pointed to one study within the Veterans health care system—the closest the nation has in equality of access to care and free treatment—that looked over time at a cohort of 260,000 patients referred to orthopedics who had similar osteoarthritis of the knee. In this environment where neither insurance nor cash payment was an issue, about 30% fewer African American patients elected to have the surgery compared white veterans.

Another VA study examining patient perspectives on treatment options—including physical therapy, chiropractic care, herbal medicine, massage, prayer, and surgery—found that African American patients were significantly less likely to endorse knee replacement surgery as a treatment option.

“We found significant differences between white and Black veterans in their expectations of surgery. Minority patients were more likely to anticipate difficulty walking afterward, greater pain, and longer recovery times,” Ibrahim said.

“One of the other questions we put to them was, ‘If your doctor recommends knee or hip replacement, will you do it?’ Minority patients were nearly 50% less likely to say yes to that. Clearly, minority patients perceive the usefulness of knee and hip replacement differently, and they are less willing to actually consider this as an option upfront.”

What About Surgeon Bias?

“And then,” Ibrahim pointed out, “there was another elephant in the room. What about the orthopedic surgeons? To get a knee replacement, patients had to have an orthopedic surgeon recommend that treatment. Was it possible that orthopedic surgeons were less likely to recommend the treatment for minority patients? Could that be the explanation? So, we did another study of veterans, half African American and half white, whose visits with an orthopedic doctor were audio recorded. This study found that if you don’t take into consideration things like age or disease severity or insurance, or patient baseline preference, minority patients are about 40% less likely to be recommended for the treatment.”

“Surgeons often assess how prepared a patient is for a major operation, since recovery requires significant rehabilitation,” Ibrahim said. “If a patient does not seem ready—emotionally or otherwise—they may be less likely to recommend surgery.”

In other words, orthopedic surgeons may not be overtly discriminating against minority patients. Instead, they are responding to how patients communicate about their condition—communication patterns that can vary across cultures and, in turn, influence whether surgery is recommended.

Educational Intervention

“So, what could be done about this? That was our next study,” Ibrahim said. “The National Institutes of Health (NIH) funded us to identify an educational intervention about the risks and benefits of surgery that might help level the playing field between minority and non-minority patients. In a randomized controlled trial, we enrolled 639 patients who potentially needed knee replacement and were referred to orthopedic surgery clinic for further care. Before patients saw the surgeon, we educated them about the risks and benefits of surgery using a validated decision-aid. Then at 12 months, we assessed who underwent knee replacement, comparing those who were educated to those who we didn’t receive the educational session. It turned out that the educated patients were significantly more likely to undergo surgery. This was the first proof to us that one could close the socioeconomic or racial gap in heath care utilization using education as an intervention tool.”

Post Surgical Disparities?

“Another important line of research our team pursued was what happens to patients after undergoing joint replacement surgery? Where do they go for rehab, for instance? And is there disparity by race or ethnicity in that aspect of the care? In general, patients who undergo joint replacement surgery have one of three options for post-op care: Discharge to home without assistance; discharge to home with home health; and discharge to an institution like a nursing home for rehab. In some of our studies, we found that African American patients and patients from less affluent neighborhoods are more likely to be discharged to an institution like a nursing home compared to patients from more affluent neighborhoods. In other words, in addition to race and ethnicity, community factors may also play a role in this disparity.”

Impact of New Medicare “Bundled” Model

Ibrahim noted that the overall conditions and disparities being studied underwent a sudden change in 2016 with the launch of Medicare’s Comprehensive Care for Joint Replacement (CJR) model designed to control costs. Under the traditional fee-for-service practices, Medicare was separately billed for the individual services involved in the overall knee or hip replacement–surgery, hospital stay, rehab and follow-ups. But the new CJR system combined all of these into a single bundled package or “episode” of care that began with the surgery and extended through all the rest of the care for 90 days after discharge.

“We were very interested in whether this new model, which has been very successful in reducing costs for Medicare, might actually exacerbate or improve disparities in knee or hip replacements,” Ibrahim said. “What we, and others, found is that the program did reduce cost of care for Medicare, but differences in the rate of joint replacement utilization worsened for minority patients especially African American patients. The good news is that the model has been revised in a way that considers social factors and safety net hospitals and all that,” Ibrahim continued. “But at the beginning, it was clear that it was exacerbating the differences that we were studying.”

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