title: Determinants of patient preferences for total knee replacement: African-Americans and whites.
abstract: BACKGROUND
  Patient preferences contribute to marked racial disparities in the utilization of total knee replacement (TKR). The objectives of this study were to identify the determinants of knee osteoarthritis (OA) patients' preferences regarding TKR by race and to identify the variables that may mediate racial differences in willingness to undergo TKR.
  
  
  METHODS
  Five hundred fourteen White (WH) and 285 African-American (AA) patients with chronic knee pain and radiographic evidence of OA participated in the study. Participants were recruited from the community, an academic medical center, and a Veterans Affairs hospital. Structured interviews were conducted to collect socio-demographics, disease severity, socio-cultural determinants, and treatment preferences. Logistic regression was performed, stratified by race, to identify determinants of preferences. Clinical and socio-cultural factors were entered simultaneously into the models. Stepwise selection identified factors for inclusion in the final models (p < 0.20).
  
  
  RESULTS
  Compared to WHs, AAs were less willing to undergo TKR (80 % vs. 62 %, respectively). Better expectations regarding TKR surgery outcomes determined willingness to undergo surgery in both AAs (odds ratio (OR) 2.08, 95 % confidence interval (CI) 0.91-4.79 for 4(th) vs. 1(st) quartile) and WHs (OR 5.11, 95 % CI 2.31-11.30 for 4(th) vs. 1(st) quartile). Among AAs, better understanding of the procedure (OR 1.80, 95 % CI 0.97-3.35), perceiving a short hospital course (OR 0.81, 95 % CI 0.58-1.13), and believing in less post-surgical pain (OR 0.73, 95 % CI 0.39-1.35) and walking difficulties (OR 0.66, 95 % CI 0.37-1.16) also determined willingness. Among WHs, having surgical discussion with a physician (OR 1.96, 95 % CI 1.05-3.68), not ever receiving surgical referral (OR 0.56, 95 % CI 0.32-0.99), and higher trust in the healthcare system (OR 1.58, 95 % CI 0.75-3.31 for 4(th) vs. 1(st) quartile) additionally determined willingness. Among the variables considered, only knowledge-related matters pertaining to TKR attenuated the racial difference in knee OA patients' treatment preference.
  
  
  CONCLUSIONS
  Expectations of surgical outcomes influence preference for TKR in all patients, but clinical and socio-cultural factors exist that shape marked racial differences in preferences for TKR. Interventions to reduce or eliminate racial disparities in the utilization of TKR should consider and target these factors.
authors.affiliation: University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, Arizona, 85724, USA. CKwoh@arthritis.arizona.edu.
authors.forename: C Kent
authors.initials: CK
authors.lastname: Kwoh
authors.affiliation: University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, Arizona, 85724, USA. evina@email.arizona.edu.
authors.forename: Ernest R
authors.initials: ER
authors.lastname: Vina
authors.affiliation: University of Pittsburgh School of Public Health, 130 De Soto St., 127 Parran Hall, Pittsburgh, Pennsylvania, 15261, USA. cloonany@edc.pitt.edu.
authors.forename: Yona K
authors.initials: YK
authors.lastname: Cloonan
authors.affiliation: University of Pittsburgh School of Medicine, 130 North Bellefield Ave., 4th Floor, Pittsburgh, Pennsylvania, 15213, USA. michaeljhannon@gmail.com.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Hannon
authors.affiliation: University of Pittsburgh School of Public Health, 130 De Soto St., 127 Parran Hall, Pittsburgh, Pennsylvania, 15261, USA. BoudreauR@edc.pitt.edu.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Boudreau
authors.affiliation: University of Pennsylvania Perelman School of Medicine and Philadelphia VA Medical Center, 3900 Woodland Ave., Philadelphia, Pennsylvania, 19104, USA. Said.Ibrahim2@va.gov.
authors.forename: Said A
authors.initials: SA
authors.lastname: Ibrahim
mesh_terms: D001741:Black or African American; D000368:Aged; D019645:Arthroplasty, Replacement, Knee / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000601:surgery*; D057240:Patient Preference / Q000208:ethnology*; D044465:White People