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)是最常见的关节炎形式，也是美国最常见的慢性病之一。膝关节骨性关节炎的患病率随着年龄的增长而增加。随着美国人口老龄化，办公自动化的负担预计会增加。老年非裔美国人(AAS)膝关节骨关节炎的患病率高于白人。然而，许多研究证明，膝关节置换术的使用存在明显的种族/民族差异，这是一种治疗晚期膝骨性关节炎的有效和高使用率的选择。我们的研究团队进行了首批研究之一，以考察再生障碍性关节炎患者和白人患者在关节置换术使用方面不同的原因。我们已经发表的证据表明，与类似的白人患者相比，AA潜在的关节置换候选人在关节置换方面的偏好不同，这些差异在一定程度上是由于对治疗风险/好处的认识不同，因此对手术结果的预期也不同。各国呼吁根据这一信息采取行动，测试旨在缩小这种差距的干预措施。这项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再生障碍性关节炎患者选择和接受膝关节置换的影响的试验之一。这项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加上有针对性的咨询(动机访谈)对再障患者的偏好、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有可能接受关节置换的AA初级保健患者，如果没有明确的手术干预禁忌症，将被随机分为干预组或注意力控制组。我们将评估干预对患者偏好、期望值的影响，以及在干预后12个月内接受骨科评估转诊的可能性。这项研究的长期目标是针对关节置换的临床候选对象实施有效的干预措施，在全国范围内努力改善获得机会，减少并最终消除在使用这一有效治疗方案方面的差异。因此，本研究的具体目标是：(1)检验膝关节骨性关节炎辅助决策辅以咨询对再障患者对膝关节置换手术结果的偏好和期望的影响；(2)检验干预对再障患者骨科手术转诊率的影响；以及(3)检验干预的作用机制(结合决策辅助和采用动机访谈的咨询)。这项拟议研究的第二个目的是检查干预对再障患者膝关节置换率的影响。 公共卫生相关性：许多研究证明，膝关节置换术的使用存在明显的种族/民族差异，这是一种治疗晚期膝骨性关节炎的有效和高使用率的选择。这项研究将提供全国首批干预措施之一，旨在缓解符合治疗临床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使全国了解减少或消除慢性病管理中最显著的差距之一的战略，而且还将为提高我们社会大部分人的护理质量提供机会。

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.