Race and Preference for Knee Replacement: A Patient-Centered Intervention

描述（由申请人提供）：摘要骨关节炎（OA）是关节炎的最常见形式，也是美国最常见的慢性疾病之一。膝关节OA的患病率随着年龄的增长而增加。随着美国人口的老龄化，OA的负担预计将增加。老年非裔美国人（AAs）膝关节OA的患病率高于白人。然而，许多研究已经记录了在膝关节置换术的使用中存在明显的种族/民族差异，膝关节置换术是晚期膝关节OA的一种有效和高度使用的治疗选择。我们的研究小组进行了第一批研究之一，以检查AA和白色患者在关节置换术的使用上存在差异的原因。我们已发表的证据表明，与相似的白色患者相比，AA潜在的关节置换候选者在关节置换的偏好方面存在差异，这些差异部分是由于对治疗风险/受益的了解不同，因此对手术结局的预期不同。各国呼吁根据这一信息采取行动，测试减少这种差距的干预措施。拟议的试验是全国第一个直接评估以患者为中心的干预对AA患者对膝关节置换术的偏好和获得的影响的试验。本随机对照试验的直接目标是评估高质量、以证据为基础、以患者为中心的教育干预补充有针对性的咨询（动机性访谈）对AA患者偏好、期望和实现骨科评估转诊的可能性的影响。根据疾病的临床严重程度，AA初级保健患者是关节置换术的潜在候选人，并且没有明确的手术干预禁忌症，将其随机分配至干预组或注意力控制组。我们将评估干预对患者偏好、期望以及在干预后12个月内接受骨科评估转诊的可能性的影响。本研究的长期目标是实施针对AA的有效干预措施，这些AA是关节置换术的临床候选人，以改善获得性，减少并最终消除这种有效治疗选择的使用差异。因此，具体目标是：（1）检查膝关节骨性关节炎决策辅助工具的效果，并辅以咨询，以了解AA患者对膝关节置换术手术结局的偏好和期望;（2）检查干预措施对AA患者骨科手术转诊率的影响;（3）探讨干预的作用机制（结合决策援助和咨询使用动机访谈）。拟议研究的第二个目的是检查干预对AA患者膝关节置换率的影响。 公共卫生相关性：许多研究已经证明，膝关节置换术的使用存在明显的种族/民族差异，膝关节置换术是晚期膝关节骨关节炎的一种有效和高度利用的治疗选择。这项研究将提供美国首批干预措施之一，旨在减轻符合临床治疗适应症的患者在获得关节置换术方面的种族/民族差异。这项研究的结果不仅将为国家提供减少或消除慢性病管理中最显著差异之一的战略，而且还将为我们社会的大部分人提供提高护理质量的机会。

DESCRIPTION (provided by applicant): Abstract Osteoarthritis (OA) is the most prevalent form of arthritis and is among the most prevalent chronic conditions in the US. The prevalence of knee OA increases with age. With the aging of the US population, the burden of OA is expected to increase. The prevalence of knee OA among older African-Americans (AAs) is higher than that reported for whites. Yet numerous studies have documented the existence of marked racial/ethnic disparities in the utilization of knee replacement, an effective and highly utilized treatment option for advanced knee OA. Our research team conducted one of the first studies to examine the reasons why AA and white patients differ in utilization of joint replacement. We have published evidence demonstrating that, compared to similar white patients, AA potential candidates for joint replacement differ in their preferences for joint replacement, and that these differences are in part shaped by differences in knowledge about the risks/benefits of the treatment and consequently in expectations on surgical outcome. There are national calls to act on this information by testing interventions to reduce this disparity. The proposed trial is one of the first in the nation to directly assess the effect of a patient-centered intervention on AA patient's preferences for and access to knee replacement. The immediate goal of this randomized controlled trial is to assess the impact of a high quality, evidence-based, patient-centered educational intervention supplemented with targeted counseling (motivational interviewing) on AA patient preferences, expectations, and likelihood of achieving a referral for orthopedic evaluation. AA primary care patients who are potential candidates for joint replacement based on clinical severity of their disease who have no clear contra-indications for surgical intervention will be randomized to either intervention or attention control. We will assess the effect of the intervention on patient preference, expectations, and likelihood of receiving a referral for orthopedic evaluation within 12 months of the intervention. The long-term goal of this research is to implement effective interventions targeting AAs who are clinical candidates for joint replacement in a national effort to improve access to reduce and ultimately eliminate disparities in the utilization of this effective treatment option. Therefore, the specific aims are: (1) to examine the effect of the knee osteoarthritis decision aid supplemented by counseling on AA patient preferences and expectations regarding surgical outcome for knee joint replacement; (2) to examine the effect of the intervention on orthopedic surgery referral rates for AA patients; and (3) To examine the mechanism of action of the intervention (combined decision aid and counseling using motivational interviewing). A secondary aim of the proposed research is to examine the effect of the intervention on AA patients' rate of knee replacement. PUBLIC HEALTH RELEVANCE: Numerous studies have documented the existence of marked racial/ethnic disparities in the utilization of knee replacement, an effective and highly utilized treatment option for advanced knee osteoarthritis. This study will provide one of the first interventions in the nation designed to mitigate racial/ethnic disparity in access to joint replacement for patients who meet clinical indications for the treatment. The results of this study will not only inform the nation on strategies to reduce or eliminate one of most marked disparities in chronic disease management, but will also provide opportunities to improve quality of care for large segment of our society.