Background There are large variations in the use of knee arthroplastyamong Medicare enrollees according to race or ethnic group andsex. Are racial and ethnic disparities more pronounced in someregions than in others, and if so, why?
Methods We used all Medicare fee-for-service claims data for1998 through 2000 to determine the incidence of knee arthroplastyaccording to Hospital Referral Region, sex, and race or ethnicgroup. A total of 430,726 knee arthroplasties were performedduring the three-year study period.
Results At the national level, the annual rate of knee arthroplastywas higher for non-Hispanic white women (5.97 procedures per1000) than for Hispanic women (5.37 per 1000) and black women(4.84 per 1000). The rate for non-Hispanic white men (4.82 proceduresper 1000) was higher than that for Hispanic men (3.46 per 1000)and more than double that for black men (1.84 per 1000). Therates were significantly lower for black men than for non-Hispanicwhite men in nearly every region of the country (P<0.05).For the Hispanic population and for black women, racial or ethnicdisparities at the national level were due in part to geographicdifferences rather than to differences in the rates for differentracial and ethnic groups within geographic areas. Residentialsegregation and low income levels contributed to racial andethnic disparities in arthroplasty rates.
Conclusions In the Medicare population, the rate of surgicaltreatment for osteoarthritis of the knee varies dramaticallyaccording to sex, race or ethnic group, and region. These variationsunderscore the importance of geography and sex in determiningracial or ethnic barriers to health care.
Knee arthroplasty is an effective alternative to medical managementfor the relief of pain and improvement of function in patientswith moderate-to-severe articular disease of the knee.1,2,3The indications for this surgical procedure continue to broadenas methods of fixation improve and survival of the componentsincreases, and its use is growing at a rapid rate among Medicareenrollees.4 The use of knee arthroplasty varies according tosex and race or ethnic group, with lower rates among men, blacks,4,5and Hispanics.6 The differences between the sexes have beenattributed to the higher rate of osteoarthritis among women.7,8However, since rates of osteoarthritis are generally higheramong blacks and Hispanics than among whites,9,10,11 the possibilityof racial barriers must be considered.
The rates of knee arthroplasty also vary substantially amongregions.4,12 Regional variations in the rates of discretionarysurgery are commonly considered to reflect differences in localmedical opinion concerning the value of these procedures.4 Littleis known about regional patterns of racial disparities in kneearthroplasty and the importance of local factors in explainingsuch differences. To what extent are national rates of arthroplastylower among blacks or Hispanics because they live in regionswhere the overall rate of knee arthroplasty is lower? To whatextent are racial or ethnic differences the consequence of lowerincome levels or residential segregation?
Methods
Study Population
We used all data for Medicare beneficiaries enrolled in fee-for-serviceprograms or non–risk-bearing health maintenance organizationsfrom 1998 through 2000 to calculate rates of knee arthroplastyclassified as code 81.54 (total knee replacement) of the InternationalClassification of Diseases, Ninth Revision, Clinical Modification,which does not include reoperations. Data bases, including theDenominator File (used to determine the number of beneficiariesin a region), were provided by the Centers for Medicare andMedicaid Services. Arday et al. have found that the Medicaredesignations for black and Hispanic enrollees closely reflectself-reported racial or ethnic identity.13 However, the sensitivityof the Hispanic designation is low; fewer than half of self-identifiedelderly Hispanic people are coded as such in the Medicare claimsdata.13 Three racial or ethnic groups were defined: black, Hispanic,and non-Hispanic white (or "white"). No provisions are availablein Medicare data for multiple racial or ethnic identifications.
Study Design
We used the Hospital Referral Region as the geographic variablein the study; the Dartmouth Atlas of Health Care identifies306 such regions.14 A Hospital Referral Region is a region servedby a hospital or group of hospitals that offers cardiovascularand neurosurgical procedures, so that each Hospital ReferralRegion includes at least one tertiary care hospital. All ZIPCodes in the United States were assigned to Hospital ReferralRegions on the basis of the migration patterns of hospital useamong the elderly population. For example, if a person who livedin the Lebanon, New Hampshire, Hospital Referral Region traveledto Boston for a knee arthroplasty, the procedure would be creditedto the Lebanon, not the Boston, Hospital Referral Region.4
The unit of analysis was the rate of knee arthroplasty accordingto sex, race or ethnic group, and Hospital Referral Region.Since there are 2 sexes, 3 racial or ethnic groups, and 306Hospital Referral Regions, the number of separate observationswas 2x3x306, or 1836. The observations were analyzed as continuousat the level of the Hospital Referral Region, rather than atthe individual level, for computational reasons (since therewere 80.5 million person-years of data) and to allow the useof linear regression methods. A small fraction of patients (6.6percent) underwent two knee arthroplasties during the three-yearperiod; these events were treated independently in the statisticalanalysis.
Sampling error among small groups of Hispanics and blacks cancreate the appearance of variation in surgical rates, even ifnone exists.15 We restricted the graphic analysis to HospitalReferral Regions for which the expected number of surgical proceduresis at least 25 (of which there are 51 regions for blacks and14 regions for Hispanics), so that the 95 percent confidenceintervals for reported rates would not exceed plus or minus1.7 procedures per 1000 persons. For multiple comparisons ofracial or ethnic differences according to the Hospital ReferralRegion, hypothesis testing was performed with use of the Bonferronicorrection (the P value divided by the total number of pairwisecomparisons) to correct for the chance that in multiple comparisons,the null hypothesis would be rejected in a few regions by chancealone.16 All rates are adjusted for differences in age compositionamong Hospital Referral Regions by the use of indirect standardization,which involves multiplying the appropriate national rate bythe ratio of the crude rate to the predicted rate for the HospitalReferral Region.17
The first hypothesis was that observed disparities in nationalrates might be a consequence of the region where black or HispanicMedicare enrollees lived rather than the result of treatmentdifferences within hospitals or regions. To test this hypothesis,we first performed a regression analysis at the level of theHospital Referral Region (separately according to sex) of therates for blacks and non-Hispanic whites (306x2=612) and forHispanics and non-Hispanic whites (306x2=612), in which theindependent variable was race or ethnic group. When the regressionwas weighted by the Medicare population, the resulting coefficientfor the black or Hispanic categorical variable was simply theoverall national difference in rates.18 The regression was thenestimated after adjustment for the Hospital Referral Region,so that the new coefficient for the black or Hispanic categoricalvariable can be interpreted as the "within–Hospital ReferralRegion" racial or ethnic difference in surgical rates. If elderlypeople who were black or Hispanic had lower rates of arthroplastybecause they lived in regions where whites had lower rates ofarthroplasty, the adjusted coefficient on race and ethnic groupwould shrink toward zero in these models adjusted for the HospitalReferral Region. The results were similar when the more flexibleBlinder–Oaxaca approach was used.19,20,21
In considering potential causes of regional variation in racialor ethnic disparities, we also hypothesized that the degreeof residential segregation and differences in household incomecould explain variations in access to care.22,23,24 The indexof dissimilarity measures the hypothetical fraction of blacks(or whites) who would have to move from their neighborhoodsto other neighborhoods in order to attain perfect integration,in which the fraction of blacks in each neighborhood would beequal to the regional average.25,26 The index ranges from 0.0,for the case in which every Census block is fully integrated,to 1.0, for the case in which all blocks are entirely segregated,and is calculated on the basis of the 2000 Census at the levelof Metropolitan Statistical Areas.27 There were 232 MetropolitanStatistical Area–Hospital Referral Region matches forthe dissimilarity index for blacks (with 9 Metropolitan StatisticalAreas assigned to more than 1 Hospital Referral Region). A HospitalReferral Region was considered to have a high or low level ofresidential segregation if its dissimilarity index for blackswas above or below the sample median. Data from the 2000 Censuswere used to determine the median household income for blackand Hispanic households according to the Metropolitan StatisticalArea,28 with 235 Metropolitan Statistical Areas matched to HospitalReferral Regions. Each Hospital Referral Region was stratifiedaccording to whether the median income for blacks was aboveor below the sample median.
To determine whether racial or ethnic differences were affectedby income or residential segregation, we estimated the interactionof differences in arthroplasty rates between blacks and othergroups with the income category (high or low) and segregationcategory (high or low) for blacks. This analysis tested thehypothesis that a high income or a low degree of segregationmight attenuate existing disparities in arthroplasty rates.We also estimated separately the interaction of differencesin arthroplasty rates between Hispanic and other groups withthe Hispanic income category (high or low). The dissimilarityindex, a measure of residential segregation, is not availablefor the Hispanic population.
Results
A total of 430,726 knee arthroplasties (performed in 403,251persons in a sample of 80.5 million person-years) were reportedin the Medicare claims data from 1998 through 2000. Among women,the national rates were higher for whites (5.97 procedures per1000 women) than for Hispanics (5.37 per 1000) and blacks (4.84per 1000) (P<0.001). Among men, the gap was more pronounced:the rate for whites (4.82 procedures per 1000 men) was higherthan that for Hispanics (3.46 per 1000) and more than doublethe rate for blacks (1.84 per 1000, P<0.001). Because thepatterns of utilization were so different for men and women,sex-specific analyses were performed.
Figure 1 shows the regional dispersion in rates according tosex and race or ethnic group among blacks and non-Hispanic whites,with each circle representing one of 51 Hospital Referral Regions.Among men, there was very little overlap in the distributionof rates between blacks and whites. Table 1 shows arthroplastyrates according to race or ethnic group among men and womenfor the 30 Hospital Referral Regions with the largest blackpopulations. In 29 of the 30 Hospital Referral Regions, therates were significantly lower for black men than for whitemen. In contrast, Figure 1 shows more overlap in rates betweenblack women and white women than in rates between black menand white men. Table 1 shows that the rates were significantlylower for black women than for white women in half (15) of theHospital Referral Regions. In the remaining 15 regions wherearthroplasty rates for black and white women did not differsignificantly, according to analysis with use of the Bonferronicorrection, 7 regions had rates that were equal or higher forblack women than for white women, and 8 had rates that werelower. (Results are also shown with a conventional P value [P<0.05]that does not correct for multiple hypothesis testing.)
Figure 1. Annual Rates of Knee Arthroplasty among Medicare Enrollees in Selected Hospital Referral Regions from 1998 through 2000, According to Sex and Race or Ethnic Group (Black or Non-Hispanic White).
The rates vary according to the Hospital Referral Region in all groups, but the overlap for men is much less than that for women.
Table 1. Rates of Knee Arthroplasty among Black and Non-Hispanic White Medicare Enrollees in Selected Hospital Referral Regions, 1998–2000.
Figure 2 shows the regional dispersion in rates according tosex and race or ethnic group among Hispanics and non-Hispanicwhites for the 14 Hospital Referral Regions with sufficientlylarge numbers of Hispanic men and women. For both men and women,the overlap was considerable. In San Antonio, Texas (the regionstudied by Escalante et al.6), Houston, Miami, New York (Manhattan),and the Bronx, the arthroplasty rates for Hispanic men weresignificantly lower than those for non-Hispanic white men (Table 2).For women, there was just one region where the null hypothesiswas rejected: New York (Manhattan), where rates for Hispanicwomen were greater than those for non-Hispanic white women (P<0.001)(Table 2). No other differences in rates were significant afterthe Bonferroni correction.
Figure 2. Annual Rates of Knee Arthroplasty among Medicare Enrollees in Selected Hospital Referral Regions from 1998 through 2000, According to Sex and Race or Ethnic Group (Hispanic or Non-Hispanic White).
The rates vary according to the Hospital Referral Region in all groups, with considerable overlap.
Table 2. Rates of Knee Arthroplasty among Hispanic and Non-Hispanic White Medicare Enrollees in Selected Hospital Referral Regions, 1998–2000.
Figure 3 shows the role of geographic variation in racial andethnic differences in national knee arthroplasty rates. Therates were 4.82 procedures per 1000 for white men and 1.84 per1000 for black men at the national level, a difference of 2.98per 1000. Figure 3 also shows the difference after correctionfor the Hospital Referral Region of residence. Among black men,the difference declined slightly, to 2.50 per 1000 (95 percentconfidence interval, 2.62 to 2.39), 84 percent of the nationaldifference. The national difference between black women andwhite women was 1.13 per 1000; after correction for the HospitalReferral Region of residence, the difference was reduced to0.70 per 1000 (95 percent confidence interval, 0.83 to 0.56),62 percent of the national difference.
Figure 3. Racial or Ethnic Differences in Rates of Knee Arthroplasty among Medicare Enrollees at the National Level and with Adjustments for the Hospital Referral Region (HRR).
The differences are for the subgroups shown as compared with non-Hispanic white men and women. The I bars indicate 95 percent confidence intervals for the adjusted estimates (306x2=612 observations). Rates at the national level were calculated with infinitesimal sampling error. For black women and Hispanic men and women, the smaller magnitude of the difference in arthroplasty rates after adjustment for the region of residence shows that these subgroups tended to live in regions where the rates for non-Hispanic whites were lower than the national average. However, for black men, the region of residence had little effect on overall racial differences in the rate of knee arthroplasty.
Among men, the difference at the national level between therates for Hispanics and those for non-Hispanic whites was 1.36per 1000. After adjustment for the Hospital Referral Regionof residence, the difference for Hispanic men fell to 0.89 per1000 (95 percent confidence interval, 1.10 to 0.67), 65 percentof the national difference. Among women, the difference was0.60 per 1000; after adjustment for the Hospital Referral Regionof residence, the difference fell to 0.03 per 1000 (95 percentconfidence interval, 0.25 to 0.19), just 5 percent of the nationaldifference.
Higher income and a lower level of residential segregation appearedto mitigate the effects of racial or ethnic differences, althoughnot equally for both sexes. Among black men, living in regionswith incomes at or above the median for blacks, as comparedwith regions with incomes below the median for blacks, was associatedwith a slightly diminished difference in arthroplasty rates(2.42 vs. 2.79 per 1000, P=0.003). Among Hispanic women in regionswith incomes at or above the median for Hispanics, the rate(0.35 per 1000) was higher than that for white women; by contrast,the rate among Hispanic women in lower-income regions (0.45per 1000) was lower than that among white women (P=0.001). Amongblack women, living in a region with a low level of residentialsegregation was associated with a smaller difference in arthroplastyrates (0.46 per 1000) than living in a region with a high levelof segregation (1.05 per 1000, P<0.001).
Discussion
A recent study by the Institute of Medicine called attentionto the pervasive differences in treatments and in outcomes betweenblacks and nonblacks,29 but relatively little attention waspaid to the role of geography in these disparities. Previousstudies have not always been able to consider racial disparitiesaccording to region and sex, because of limitations in samplesize.30 Our study, drawing on 80.5 million person-years of observationin the Medicare population, suggests that patterns of differencesin the use of knee arthroplasty differ fundamentally accordingto sex, race or ethnic group, and region.
In some regions, the rate for black women was significantlylower than that for white women, whereas in other regions, therates were roughly equal. There was substantial variation bothwithin and between regions; for example, the rate for blackwomen in Greenville, North Carolina (6.2 procedures per 1000),was twice as high as that for white women in Manhattan (2.9per 1000). Roughly 35 percent of the national differences inarthroplasty rates for black women and 95 percent of the nationaldifferences for Hispanic women are explained by the fact thatblack and Hispanic women are more likely to live in regionswith lower rates for all races and ethnic groups. Schneideret al. found, analogously, that nearly half the differencesbetween blacks and whites in the rates of breast-cancer screening,use of beta-blockers, and eye examinations among patients withdiabetes were explained by the fact that black patients belongedto lower-quality health plans rather than by differences inthe quality of care for blacks and whites within the plans.31Finally, our study showed that higher degrees of residentialracial segregation (among black women) and low income (amongHispanic women and black men) were associated with larger differencesin arthroplasty rates.22,23
Arthroplasty rates were consistently lower among black men thanamong white men in nearly every Hospital Referral Region, andin some regions, such as Jackson, Mississippi, and Detroit,the rates for black men were less than one third those for whitemen. One cannot explain these persistent differences on thebasis of financial or geographic barriers alone, since the patternwas not apparent for black women living in the same neighborhoods.The pattern in arthroplasty rates is also quite different fromthe much better documented difference in rates of cardiac surgery,for which racial disparities have been found among both menand women and in a variety of settings.31,32,33,34,35,36 Incontrast to our study, Schulman et al. found that only blackwomen were less likely to be referred for cardiac catheterizationand that there was no significant difference between black menand white men.37,38
One important limitation of our study is that equality of ratesdoes not necessarily mean that the health care system is freeof bias. Variation in arthroplasty rates could be explained,for example, by differences in underlying health status. Previousstudies have suggested an increase by a factor of 1.5 to 2.0in the incidence of osteoarthritis in women,8,10 a differencethat is not matched by correspondingly higher arthroplasty rates.8Hirsch et al. found that among women over the age of 60 years,38 percent of non-Hispanic whites, 61 percent of non-Hispanicblacks, and 44 percent of Mexican-Americans had radiologic signsof knee osteoarthritis; the corresponding proportions of menwere 31 percent, 43 percent, and 39 percent.9 It is difficultto define the appropriate null hypothesis of racial or ethnicequality without adjusting for the underlying incidence of disease.39Another limitation of our study is the difficulty of detectingracial or ethnic differences in rural areas with small numbersof black or Hispanic Medicare patients.
How much of the regional variation in knee arthroplasty canbe explained by differences in the rates of underlying disease?Hawker et al. compared two regions in Canada — one withhigh rates of hip and knee arthroplasty and one with low rates— and found differences in potential need of at most 27percent, depending on how need was defined.40 Although healthstatus is likely to explain part of the observed variation inour study, it is unlikely to account entirely for the overalldifferences among regions.
Another possible cause of variation in arthroplasty rates isdifferences in patients' preferences. Although arthroplastyhas been shown to be a superior alternative to medical managementfor improving function and decreasing pain in patients withosteoarthritis of the knee,1,2,3,41 it carries a small riskof death or long-term complications, which may include infection,neurologic injury, and the need for reoperation. Patients' preferencesshould therefore have a role in determining rates of knee arthroplastyaccording to sex, race or ethnic group, and region. Previousresearch has shown that black patients are less willing thanwhite patients to undergo risky cardiac surgery, largely becausethey are less familiar with the procedures.36 Blacks also reportless confidence in the efficacy of knee or hip replacement,42suggesting that lack of information about risks and benefits,43compounded by general distrust of the health care system,44is a partial determinant of the observed lower operation rates.
These studies raise the question, already posed in the literatureon regional variation in rates of health care interventions,"Which rate is right?"45 Presumably, the right rate would beachieved if the procedure were performed in every patient whocould clinically benefit from it and who wanted it done. Buthow do clinicians determine what patients really want? Katzhas distinguished between choices "guided by informed decisions"and choices "limited by truncated opportunities or historicalcircumstances,"46 and that distinction seems appropriate here.
Although efforts to erase disparities at the local level willhave important benefits, particularly among black men, evenperfect equality in rates of knee arthroplasty according torace or ethnic group at the local level will not eradicate alldisparities at the national level. Finally, ensuring that patientsare well informed about the potential benefits and costs ofsurgery and are allowed to make choices free of economic orgeographic barriers to care is an important step in solvingthe problem of disparities in rates of knee arthroplasty.47,48
Supported in part by grants from the National Institute of Arthritisand Musculoskeletal and Skin Diseases (MRCP60-AR048094-01A1,U01-AR45444-01A1) and from the National Institute on Aging (KO1AG00752 and PO1 AG19783), the Robert Wood Johnson Foundation,the American Academy of Orthopedic Surgeons, and the AmericanHospital Association.
We are indebted to Tamara Morgan, Kristen Bronner, Cindi Kreiman,and Stephanie Raymond for invaluable assistance in the preparationof the manuscript.
Source Information
From the Center for the Evaluative Clinical Sciences and Community and Family Medicine, Dartmouth Medical School, Lebanon, N.H. (J.S., J.N.W., J.E.W.); the Department of Economics, Dartmouth College, Hanover, N.H. (J.S.); the Department of Orthopedics, Dartmouth–Hitchcock Medical Center, Lebanon, N.H. (J.N.W., S.M.S.); and the National Bureau of Economic Research, Cambridge, Mass. (J.S.).
Address reprint requests to Dr. Weinstein at the Dartmouth–Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756, or at james.weinstein{at}dartmouth.edu.
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