Race, ZIP Code Predict Knee Procedure

Black men in some cities far less likely to have replacement

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By
HealthDay Reporter

WEDNESDAY, Oct. 1, 2003 (HealthDayNews) -- The color of your skin and your address play a major role in how likely you are to have surgery for knee arthritis, says new research which finds black men have the procedure much less often than whites.

Although whites have the operation more than blacks and Hispanics on the national level, the picture changes from city to city. In some areas of the country, there are no significant differences in rates of knee replacement surgery between black, white and Hispanic women. But in the same places, black men are far less likely to undergo the procedure than men in the other two ethnic groups. In Memphis, Detroit and Jackson, Miss., for example, black men have less than a third the number of knee replacements as do white male residents of those cities.

The study is far from the first to uncover racial differences in health care in the United States. A 2002 report from the Institute of Medicine declared that minorities in this country "receive a lower quality of health care than non-minorities," even after accounting for insurance, income and other factors that might affect access to medical services. But experts say the latest work is among the first to so carefully explore the impact of geography on the equation.

"Where you get care has a lot to do with how much care you get," says health economist James Knickman, vice president of the Robert Wood Johnson Foundation, which helped fund the new research. A report on the findings appears in the Oct. 2 issue of the New England Journal of Medicine.

"There are times you get less care, but it doesn't hurt you," says Knickman, co-author of an editorial accompanying the journal article. "But in this case, getting it when you need it is good quality medicine."

Knee arthroplasty involves replacing damaged joints with artificial versions typically made of metal and plastic. The elective operation relieves pain and restores mobility in people with osteoarthritis, "wear-and-tear" destruction of the joints that affects roughly 20 million Americans. Doctors in this country now perform nearly 270,000 total knee replacements each year, according to the American Academy of Orthopaedic Surgery.

The latest study looked at rates of knee replacement surgery among all fee-for-service Medicare beneficiaries between 1998 and 2000 -- or almost the entire adult population of the country. During that time, 430,726 of the operations were performed.

Knee replacement was more common among whites than either blacks or Hispanics. White women had the highest rate -- nearly six per 1,000 people -- compared with 5.37 per 1,000 for Hispanics and 4.84 for blacks.

Among men, the disparities were even greater: 4.82 procedures per 1,000 whites, 3.46 per 1,000 for Hispanics, and 1.84 per 1,000 for blacks.

But the differences became even more pronounced when the researchers plotted knee replacements on the map. "Even within the same city you can observe almost no differences in rates for women [of varying ethnicities] but huge differences for men," says study author Jonathan Skinner, an economist at Dartmouth Medical School.

The geography gap applied across all three ethnic groups. Indeed, for Hispanics ZIP code explained essentially all the difference in surgery rates. White women in New York City had the lowest rate of knee replacements for that group, at two per 1,000, while their counterparts in St. Louis had the highest rate, at 7.2 per 1,000.

Yet the effect of geography was particularly potent for black men, who had the lowest rates of knee replacement surgery in virtually every city studied.

What accounts for the racial differences is murky, Skinner says. Blacks tend to express more skepticism than whites about knee surgery, he says. However, he adds, "it's not clear whether this skepticism is because of poorer information, a greater concern about the risks of surgery, or a general distrust of the health-care system because of previous adverse encounters with health providers."

Dr. Said A. Ibrahim, a researcher at the University of Pittsburgh who has studied racial differences in knee replacement surgery, says he and his colleagues have found that blacks typically aren't as familiar as whites are with the procedure. "They don't have friends or relatives who have had it in the past," he says. Knowing that, Ibrahim suggests that doctors make an extra effort to educate black patients about the operation.

More information

For more on knee replacement, try the American Academy of Orthopaedic Surgery. For more on health disparities and race, check out the U.S. government's Office on Minority Health or the National Academy of Sciences.

SOURCES: Jonathan Skinner, Ph.D., professor, family and community medicine, Dartmouth Medical School, Hanover, N.H.; Said A. Ibrahim, M.D., M.P.H., assistant professor, medicine, University of Pittsburgh Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh; James Knickman, Ph.D., vice president, Robert Wood Johnson Foundation, Princeton, N.J.; Oct. 2, 2003, New England Journal of Medicine

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