Race, Ethnicity, Insurance Coverage, and Preoperative Status of Hip and Knee Surgical Patients

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1 The Journal of Arthroplasty Vol. 19 No Race, Ethnicity, Insurance Coverage, and Preoperative Status of Hip and Knee Surgical Patients Carlos J. Lavernia, MD,* David Lee, PhD, Rafael J. Sierra, MD, and Orlando Gómez-Marín, MSc, PhD Abstract: Our objective was to examine the association between race/ethnicity and insurance type and the preoperative status of patients undergoing joint arthroplasty surgery. Quality of life and WOMAC measures were collected preoperatively in a consecutive series of patients undergoing primary hip or knee arthroplasties (n 573). Non-Hispanic whites had lower preoperative pain and WOMAC scores and higher Quality Well Being Index and SF-36 scores compared with other racial/ethnic subgroups. Patients with Medicare/private insurance had better preoperative scores relative to patients with Medicaid or no insurance. Racial/ethnic status was generally more strongly associated with preoperative status than was insurance type. Hispanics, blacks, and patients without Medicare or private health insurance reach arthroplasty surgery with lower preoperative functional and health status. Key words: arthroplasty surgery, race, ethnicity, Medicare, Medicaid Elsevier Inc. All rights reserved. Approximately 500,000 total joint arthroplasty surgeries are performed every year in the United States [1]. These numbers are expected to increase as the population ages. The number of persons 65 years of age and older is projected to increase from From the *Orthopedic Institute at Mercy Hospital, Miami, Florida; the Departments of Orthopedic Surgery and Biomedical Engineering, University of Miami, Miami, Florida; the Departments of Epidemiology and Public Health and Pediatrics, University of Miami, School of Medicine, Miami, Florida; and the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota. Submitted August 27, 2003; accepted April 2, Benefits or funds were received in partial or total support of the research material described in this article from Zimmer, Warsaw, Indianna; the American Association of Hip and Knee Surgeons, the Orthopaedic Research and Education Foundation, Chicago, Illinois; the Arthritis Surgery and Research Foundation, Miami, Florida; and the Mercy Foundation, Miami, Florida. Reprint requests: Carlos J Lavernia, MD, 3659 South Miami Avenue, Suite 4008, Miami, FL Elsevier Inc. All rights reserved /04/ $30.00/0 doi: /j.arth nearly 35 million in 2000 to nearly 79 million by 2050 [2]. Furthermore, Americans 85 years of age and older comprise the fastest-growing age group in the United States; their numbers are expected to increase over 4-fold from the years 2000 to Hispanics are now the largest minority group in the United States [3]. Both the black and Hispanic populations are projected to comprise a larger percentage of the total American population in the coming years; their numbers are projected to increase 70% and 300%, respectively, from 2000 to 2050 [2]. By 2050, the number of blacks and Hispanics age 65 and older is estimated to increase to 8.6 million and 13.8 million, respectively. Numerous studies published in the last 14 years have documented that African Americans and Hispanics undergo joint arthroplasty at lower rates than non-hispanic whites [4 10]. The reasons for these differences in surgical rates are only gradually coming under study by investigators. However, re- 978

2 Race, Ethnicity, and Insurance in Arthroplasty Lavernia et al. 979 search in other fields of medicine indicate that the causes of health disparities are multifactorial and include patient-level factors such as delay in seeking care and treatment refusal, as well as limited access to health care, language barriers, and healthcare provider bias and stereotyping [11]. One effect of these health disparities is that minorities with arthritis may delay seeking surgery until their disease has progressed to advanced stages. Unfortunately, it is not known if minority patients do present for surgery with more advanced disease and poorer functional status. Careful review of the largest arthroplasty series published over the last 5 years in major orthopedic journals shows that the majority of patients in those cohorts are of Anglo origin. To our knowledge, the association of race, ethnicity, and insurance coverage on the pain level, functional capacity, and quality of life of patients undergoing arthroplasty has not been previously reported in the literature. It is therefore essential to determine if adults who have traditionally reported barriers to healthcare (eg, minorities and the underinsured) are more likely to present for arthroplasty surgery with more advanced disease and reduced function relative to nonminority patients and patients covered under Medicare or other private health insurance plans. Patient Selection Materials and Methods Table 1. Sociodemographic Characteristics of Study Participants Characteristic Number Percentage Sex Males Females Race/Ethnicity Hispanic whites Non-Hispanic whites Hispanic blacks Non-Hispanic blacks Insurance type Medicare Medicaid/indigent Private From August 1992 to January 2000, a consecutive series of patients with a diagnosis of end-stage arthritis seen by the senior author (C.J.L.) at his private or academic clinic were enrolled in the study. End-stage arthritis was diagnosed based on patient symptomatology and radiographic findings. Sociodemographic information was obtained from questionnaires administered to patients at their first office visit and at their preoperative evaluation. The current study included patients with only primary hip or knee arthroplasties who had a preoperative outcome evaluation within 2 weeks of surgery. The second surgery for patients undergoing bilateral hip or knee surgery on the same day was excluded from the analyses. This was also performed for patients undergoing staged primary hip or knee arthroplasty. A total of 816 primary hip or knee arthroplasties have been performed in our unit since August Of these, 77 were excluded either because they were primary conversions from hemiarthroplasties or because the patient had not been evaluated preoperatively with an outcome instrument. This left a total of 739 primary total hip or knee arthroplasties performed on 573 patients (293 hip and 280 knee). The mean age of the cohort was 62.7 years (standard deviation [SD] 14.1). The sociodemographic distribution of study patients is shown in Table 1. Of the total number of patients, 361 (63.2%) were females, and 328 (57.3%) were of Hispanic origin. Within the Hispanic subgroup, 215 were Cuban/Cuban American, 82 were South or Central American, 13 were Puerto Rican, 5 were Mexican/Mexican American, and 13 were Spanish. In the present analysis, participants were classified as: Hispanic whites, 300 patients (52.4%); non- Hispanic whites, 157 (27.4%); Hispanic blacks 28 (4.9%); and non-hispanic blacks, 88 (15.4%). Patients were also classified by type of insurance coverage, which was approximately evenly distributed across Medicare (38%), Medicaid/indigent (31%), and private insurance (31%). Outcome Measures The Quality Well Beinq Index. The Quality of Well Being (QWB) Index was developed by Kaplan et al to assess general quality of life [12]. This index has been validated for use in a variety of populations, including African Americans and Hispanics [13]. Short Form 36. The Short Form 36 (SF-36) is a thoroughly validated measure of general physical and mental health status that has been used in African Americans, Hispanics, and non-hispanic whites [14,15]. The SF-36 contains 8 different subscales, including physical function, bodily pain, mental health, social function, role limitation caused by physical function, role limitation caused by emotional problems, and vitality, as well as

3 980 The Journal of Arthroplasty Vol. 19 No. 8 December 2004 general health perceptions. All domains are scored separately on a 0- to 100-point scale, with higher numbers representing better health status. The pain and function subscales have shown to be the most sensitive to change in osteoarthritis patients following surgery [15]. Western Ontario and McMaster University Osteoarthritis Index. The Western Ontario and Mc- Master University Osteoarthritis Index (WOMAC) has become another current standard for evaluating results of total hip and knee arthroplasty surgery [16]. It is designed to provide information on the patient s level of stiffness, pain, and function. The WOMAC consists of 24 items (5 for pain, 2 for stiffness, and 17 for function). Point values from 0 to 5 are assigned to each response, and scores are totaled for each category. WOMAC scores range from 0 to 96 (the worst possible score). Analog Pain Measures. Two analog pain scales were administered. Participants were presented a line bordered with the numbers 0 to 10. They were instructed to mark the point along this line that best reflected the intensity and frequency of joint pain. Higher scores on these measures reflected greater levels and frequency of joint pain. Surgical Protocol All surgeries were performed by the senior author (C.J.L.), and the same conservative protocol before the surgical intervention was followed. Conservative care included the appropriate use of 2 nonsteroidal anti-inflammatory drugs (longer than 1 month each), weight loss, and preoperative training in the use of a cane. Patients who continued to have severe symptoms after medical treatment were considered for surgery and scheduled within the following 2 months. Statistical Analysis The SPSS software was used for the statistical analyses. The Kruskall-Wallis test was used to compare preoperative measures among patients grouped by race/ethnicity and insurance status. Post-hoc tests to determine differences between 2 groups were completed using the Mann-Whitney test; a more conservative P value of.01 was selected to adjust for multiple comparisons. A 2-way analysis of variance (ANOVA) with interaction was used to assess the joint influence of race/ ethnicity and insurance. Before these analyses, the normality of the distribution of the preoperative outcome measures was assessed, and, if necessary, the data were statistically transformed to approximate a normal distribution. Results The functional and health status of study participants tabulated by racial/ethnic background is shown in Table 2. There were significant differences in all preoperative scores across the 4 race/ethnicity categories (all P values were.05). For each comparison, either Hispanic blacks or non-hispanic blacks reported the lowest QWB and SF-36 scores, and the highest WOMAC and pain analog scores, although differences between these scores and those for Hispanic and non-hispanic whites were not always statistically significant. Preoperative QWB and SF-36 scores were consistently higher, and pain and WOMAC measures were consistently lower, in non-hispanic whites than in any other racial/ethnic group. Non-Hispanic whites had significantly lower scores on the pain analog frequency and intensity scales relative to the other racial/ethnic groups. In addition, non-hispanic whites also had significantly higher scores in the Role Emotional subscale of the SF-36 than did Hispanic whites, Hispanic blacks, and non-hispanic blacks (P.01 for each comparison). Non-Hispanic whites generally had higher QWB and SF-36 scores and lower pain scores than Hispanic whites. One notable exception was the significantly higher SF-36 vitality score for Hispanic whites versus non- Hispanic whites (P.01). Hispanic blacks and non- Hispanic blacks generally had similar scores on all preoperative measures. Hispanic blacks did have lower scores on the Role Emotional subscale of the SF-36 relative to non-hispanic blacks (18.48 vs 38.16), but this difference was not statistically significant. This lack of significance is, in part, the result of the relatively few Hispanic black participants in the analysis (n 28). There were significant differences for most, but not all, comparisons of preoperative measures across categories of patients with private insurance, Medicare, and Medicaid or who were indigent (Table 3). Post-hoc comparisons indicated there were no significant differences on any preoperative measure between patients with Medicare versus patients with private insurance. Patients with private insurance or who were covered by Medicare had consistently higher preoperative QWB and SF-36 scores and had consistently lower pain and WOMAC scores relative to patients with Medicaid or those who were indigent. These differences were

4 Race, Ethnicity, and Insurance in Arthroplasty Lavernia et al. 981 Table 2. Mean Preoperative Scores and Standard Errors for Quality of Life, Functional Status, and Pain Measures According to Patient Racial/Ethnic Background Instrument Hispanic White (H-W) Racial/Ethnic Category Non-Hispanic White (NH-W) Hispanic Black (H-B) Non-Hispanic Black (NH-B) ANOVA Mean SE Mean SE Mean SE Mean SE P Contrast QWB total score A, E SF-36 Physical Function Role Emotional A, D, E Body Pain D, E Mental Health A, D Vitality A, C Role Playing A, D General Health C, E Social Function E WOMAC Total A, E Pain E Function A, E Stiffness C Pain Analog Intensity A, D, E Frequency A, D, E Abbreviations: A, contrast between H-W and NH-W, P.01; B, contrast between H-W and H-B, P.01; C, contrast between H-W and NH-B, P.01; D, contrast between NH-W and H-B, P.01; E, contrast between NH-W and NH-B, P.01; F, contrast between H-B and NH-B, P.01. statistically significant for the QWB measure; the SF-36 bodily pain measure; and the WOMAC total, pain, and function measures (all P values were.01). A cross-tabulation between racial/ethnic background and insurance coverage was completed before undertaking the 2-way ANOVA (Table 4). Among the Hispanic white subgroup, 39.3% had Medicare, 38.0% had Medicaid or were indigent, and 22.6% were privately insured. More than 52% of non-hispanic whites were privately insured, whereas only 8.3% had Medicaid or were indigent. In contrast, 53% of Hispanic blacks had Medicaid or were uninsured, whereas only 10.7% were privately insured. Nearly 39% of non-hispanic blacks had Medicaid or were not insured. Results of this cross-tabulation indicate that there are an insufficient number of Hispanic blacks for the 2-way ANOVA. Because preoperative scores of Hispanic blacks and non-hispanic blacks were generally similar, these 2 groups were combined for these analyses. Table 5 shows the F-values for the main effects (ie, race/ethnicity and insurance type), along with the F-values for the interaction terms. There were no interactions between the race/ethnicity category and insurance status for any of the preoperative measures. Both race/ethnicity and insurance type were independently and significantly associated with selected preoperative measures, including the QWB and the WOMAC Total and Function scales. Overall, associations with the outcome measures tended to be stronger for race/ethnicity than for insurance status. In no instance was insurance status significantly associated with a preoperative measure in the absence of significant association with race/ethnicity. However, in several instances, race/ethnicity was significantly associated with a preoperative measure in the absence of a significant association with insurance status (ie, SF-36 Role Play, General Health, Vitality, Social Function and Role Emotional, the WOMAC pain and stiffness scales, and the pain analog intensity scale). Discussion This study is the first to examine the joint influence of race/ethnicity and insurance type on preoperative functional status in patients undergoing arthroplasty of the hip or knee. Our results indicate that both factors are independently associated with

5 982 The Journal of Arthroplasty Vol. 19 No. 8 December 2004 Table 3. Mean Preoperative Scores and Standard Errors for Quality of Life, Functional Status, and Pain Measures According to Type of Patient Insurance Instrument Insurance Type Medicare Medicaid/Indigent Private Insurance ANOVA Mean SE Mean SE Mean SE P Contrast QWB Total Score A, C SF-36 Physical C Function Role Emotional C Body Pain A, C Mental Health C Vitality Role Playing C General Health Social Function WOMAC Total A, C Pain A, C Function A, C Stiffness Pain Analog Intensity C Frequency C Abbreviations: A, contrast between Medicare and Medicaid/indigent, P.01; B, contrast between Medicare and Private, P.01; C, contrast between Medicaid/indigent and Private, P.01. selected functional measures such as the QWB and the WOMAC. There was no evidence of any interactions that would suggest that particular race/ethnic subgroups present for surgery in a better or worse functional state when they have a particular type of insurance. Rather, these results indicate that the race/ethnic status of this group of patients tended, in general, to be more strongly associated with preoperative outcome measures than did insurance type. The reasons for such a finding are unclear, and additional research is needed to determine why blacks and Hispanics are presenting for hip and knee surgery with more pain, less function, and worse quality of life than are non-hispanic white patients. These findings have important implications for orthopedic patients given that the senior author has reported data about which surgical interventions in patients with more pain and less function lead to suboptimal outcomes [17]. Previous research in male Veterans Affairs patients with hip and knee pain failed to find differences in WOMAC pain scale scores in blacks versus whites when stratified by radiographic severity of osteoarthritis [18]. Thus, there is no evidence that blacks and whites are systematically more or less likely to report arthritis-related pain. In our study, non-hispanic black patients demonstrated higher pain levels as assessed by the pain analog and WOMAC scales, suggesting that they are presenting Table 4. Cross-tabulation of Study Participants by Racial/Ethnic Background and Type of Insurance Coverage Racial/Ethnic Background Insurance Type Medicare Medicaid/Indigent Private Total Number Hispanic white Non-Hispanic white Hispanic black Non-Hispanic black Total number

6 Race, Ethnicity, and Insurance in Arthroplasty Lavernia et al. 983 Table 5. Main Effects and Interaction Terms Examining the Joint Association of Racial/Ethnic Background and Insurance Status on Quality of Life, Functional Status, and Pain Measures Instrument* Main Effect Insurance (F-value) Main Effect Race/Ethnic (F-value) Race-insurance Interaction (F-value) QWB Total Score SF-36 Physical Function Role Emotional Body Pain Mental Health Vitality Role Playing General Health Social Function WOMAC Total Pain Function Stiffness Pain Analog Intensity Frequency *Skewed measures were log- or square-root-transformed to approximate normal distributions before completing the 2-way ANOVA. P.05. to the surgical intervention with a more advanced stage of disease relative to non-hispanic whites. Cultural and behavioral factors may account, in part, for a delay in seeking surgical intervention. Black male arthritis patients are approximately 50% less likely to perceive joint arthroplasty therapy as an efficacious treatment approach relative to whites [19]; blacks are also less likely to report that they had a friend or family member who underwent joint arthroplasty therapy (52% vs 78%) [20]. Finally, glucosamine/chondroitin use is approximately 50% lower in black versus white arthritis patients [21]. It is also possible that the underlying arthritic disease process may differ between blacks and whites, and once ensued, may progress more rapidly, leading black patients to present with more severe disease. Unfortunately, the biological and genetic factors that influence arthritis disease progression are poorly understood [22]. Longitudinal studies of blacks and other minorities with earlystage arthritis are needed to understand the role that these factors, as well as healthcare access and healthcare-seeking behaviors, play in influencing presentation for surgical intervention [23]. Hispanics may receive inadequate information about complex surgical procedures as a result of language barriers. In our study, many Hispanic patients that have Medicaid or are uninsured do not speak English. The senior author has noted that many of the older Hispanic females, because of cultural beliefs or fears, may, despite having severe pain, elect not to have the surgical intervention. These patients wait many months or years, and only decide to have the surgical intervention when the arthritic pain becomes excruciating and they become wheelchair-bound. As is the case for blacks, little is known about the natural history of arthritis progression in Hispanics. Furthermore, there is no information on factors that influence the contemplation of surgical intervention among Hispanics. Such a study is warranted given that Hispanics generally had poorer preoperative scores relative to non-hispanic whites in the present study. It is important to note several study limitations. First, we had relatively few blacks enrolled in this study, which limited statistical power. In addition, all study participants were recruited from a single surgical practice located in south Florida. Study findings should therefore not be generalized to other regions of the U.S. For example, the majority of Hispanic participants in the present study were Cuban Americans. Although sharing a common language, Hispanic subgroups in the U.S. vary significantly in terms of genetics and such factors as sociodemographic characteristics, health behaviors, and perceived access to healthcare [24 26]. For instance, for Mexican Americans, the gene pool

7 984 The Journal of Arthroplasty Vol. 19 No. 8 December 2004 contribution is estimated to be 61% Spanish, 31% Native American, and 8% African, whereas estimates for Cuban Americans are 62%, 18%, and 20%, respectively [26]. To summarize, this study found that that both insurance type and race/ethnicity were related to preoperative status of arthroplasty patients; when both factors were considered simultaneously, race/ ethnic status tended to have stronger associations with preoperative status than health insurance status. Hispanics, blacks, the uninsured, and patients with Medicaid had generally poorer preoperative scores. Surgeons and healthcare providers must understand how different factors may affect the steps that lead to arthroplasty so that pertinent interventions can be undertaken to increase the access to arthroplasty surgery for minority groups and patients lacking health insurance. These factors can ultimately be addressed through appropriate public health and policy measures, as well as targeted educational interventions. Acknowledgment We acknowledge the assistance of Victor Hugo Hernandez, MD. References 1. Callaghan JJ, Forest EE, Olejniczak JP, et al: Charnley total hip arthroplasty in patients less than fifty years old: A twenty to twenty-five years follow-up note. J Bone Joint Surg Am 80:704, Cheeseman J: Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050, U.S. Bureau of the Census, Current Population Reports, Available at: prod/1/pop/p /p pdf. Accessed February 17, US Census Bureau: Hispanic population reaches alltime high of 38.8 million, new census bureau estimates show. Available at: Press-Release/www/releases/archives/hispanic_origin_ population/ html. Accessed February 17, White RH, McCurdy SA, Marder RA: Early morbidity after total hip replacement: rheumatoid arthritis versus osteoarthritis. J Gen Internal Med 5:304, Gittelshon AM, Halpern J, Sanchez RL: Income, race and surgery in Maryland. Am J Public Health 81: 1435, Sharkness CM, Hamburger S, Moore RM, et al: Prevalence of artificial hip implants and use of health services by recipients. Public Health Rep 108:70, Friedman B, Elixhauser A: Increased use of an expensive, elective procedure: total hip replacements in the 1980 s. Medical Care 31:581, Wilson MG, May DS, Kelly JJ: Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethnicity Dis 4:57, Hoaglund F, Oishi C, Gialamas G: Extreme variations in racial rates of total hip arthoplasty for primary coxarthrosis: a population-based study in San Francisco. Ann Rheum Dis 54:107, Escalante A, Espinosa-Morales R, Del Rincon I, et al: Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum 43: 390, Smedley BD, Stith AY, Nelson AR (eds): Unequal treatment: Confronting racial and ethnic disparities in health care. Institute of medicine. The National Academies Press, Washington, DC, 2003, pp Kaplan RM, Bush JW: Health-related quality of life measurement for evaluation research and policy analysis. Health Psychology 1:61, Kaplan RM, Alcaraz JE, Anderson JP, et al: Qualityadjusted life years lost to arthritis: effects of gender, race and social class. Arthritis Care Res 9:473, Arocho R, McMillan CA, Sutton-Wallace P: Construct validation of the USA-Spanish version of the SF-36 health survey in a Cuban-American population with benign prostatic hyperplasia. Qual Life Res 7:121, Lieberman JR, Dorey F, Shekelle P, et al: Outcome after total hip arthroplasty: Comparison of a traditional disease-specific and a quality-of-life measurement of outcome. J Arthroplasty 12:639, Bellamy N, Buchanan WW, Goldsmith CH, et al: Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833, Lavernia CJ, Hernandez RA, Sierra RJ: Timing the surgical intervention in arthroplasty surgery: optimizing the outcome. Presented at the AAHKS Ninth Annual Fall Meeting, Poster Session, Dallas, TX, November 30, Ang DC, Ibrahim SA, Burant CJ, et al: Is there a difference in the perception of symptoms between African Americans and whites with osteoarthritis? J Rheumatol 30:1305, Ibrahim SA, Siminoff LA, Burant CJ, et al: Variation in perceptions of treatment and self-care practices in elderly with osteoarthritis: a comparison between African-American and white patients. Arthritis Care Res 45:340, 2001

8 Race, Ethnicity, and Insurance in Arthroplasty Lavernia et al Ibrahim SA, Siminoff LA, Burant CJ, et al: Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patientlevel factors. Medical Care 40(suppl 1):I44, Mikuls TR, Mudano AS, Pulley L, et al: The association of race/ethnicity with receipt of traditional and alternative arthritis-specific health care. Med Care 41:1233, Felson DT: Ostroarthritis: New insights: Part 1: the disease and its risk factors. Ann Intern Med 133:635, Jordan JM, Lawrence R, Kington R, et al: Ethnic health disparities in arthritis and musculoskeletal diseases: Report of a Scientific Conference. Arthritis Rheum 46:2280, Kerner JF, Dusenbury L, Mandelblatt JS: Poverty and cultural diversity: challenges for health promotion among the medically underserved. Ann Rev Publ Health 4:355, Delivering Preventive Health Care to Hispanics: A Manual for Providers. The National Coalition of Hispanic Health and Human Services Organizations. Washington DC, Hanis CL, Hewett-Emmett D, Bertin TK, et al: Origins of U.S. Hispanics: Implications for diabetes. Diabetes Care 14:618, 1991