A clinical trial that quietly launched earlier this month is testing how the use of a shared decisionmaking tool affects the way minority patients decide on treatment for knee pain — and whether they are healthier and happier as a result.
“If we engage the patient, can we improve their experience and their care?” said Dr. Michael Parks, an orthopedic surgeon at Hospital for Special Surgery in New York who is leading the study. “By doing this, maybe we can move the needle on disparities.”
The multi-center, randomized controlled trial began at Hospital for Special Surgery, the primary site, in August. It will ultimately be rolled out at a total of eight sites across the US and involve 360 patients with knee osteoarthritis.
The study is aimed at African-Americans and Latinos, according to Parks. “We're targeting those patients that we have defined to be most affected by healthcare disparities,” he explained.
Socioeconomic and racial disparities in health are well documented, and a wide body of research continually reveals more about how related social determinants—where people live, learn, work and play — influence their health.
Minorities and those living in poverty often have less access to healthcare, which tends to be of worse quality for a “large proportion of measures,” the federal Agency for Healthcare Research and Quality found in its 2013 National Healthcare Disparities Report.
While these negative consequences are well established, the path to mitigating and addressing them is less clear cut.
“How do we approach it? How do we tackle this complex issue? I think that's where the rubber meets the road,” said Dr. Regina James, director of clinical and health services research at the National Institute on Minority Health and Health Disparities, part of the National Institutes of Health.
“There really is no magic bullet,” James added. “We're really going to have to take this multidimensional approach to interventions.” In that vein, the NIMHD recently announced that it would fund new research to comprehensively study the impact of a person's surroundings—the family and community, plus the healthcare system—on his or her health.
It's as a part of the latter dimension where the tool being tested in the new clinical trial comes into play.
Minorities—specifically, blacks, Hispanics, Asians, Native-Americans and people of mixed races—receive knee replacements at lower rates than whites, and when they do, they have higher rates of adverse outcomes, a recent study by Parks and several other researchers showed. More nuances emerge within population subsets, such as the fact that being poor worsens knee replacement outcomes more so for blacks than for whites, other research by Parks has shown.
To Parks, his research highlighted the need to better understand how a combination of race and social factors, such as living in poverty or in a food desert, can “create a vicious cycle that feeds back on underutilization of care, and perhaps poor outcomes in joint replacement surgery,” Parks said.
He wanted to understand why people, minorities in particular, were less likely to take advantage of treatment, including surgery, that would allow them to lead better lives. “Many patients are content to do nothing,” he said. “I'm not sure what the origin is, but there's a fear, in some instances, of proceeding with intervention.”
The shared decisionmaking tool lays out for patients a plethora of permutations of the cost and outcomes of varying treatments for knee pain. It allows patients to compare wearing a brace, for instance, with getting a knee replacement, delaying treatment or forgoing it altogether.
“The patient gets to see that there's a cost to doing nothing,” Parks said. A systematic review of decision aids in general, published in 2011, found that some of these tools “improve informed values-based choices,” but called for further evaluation to better understand the impacts of specific decisionmaking tools on areas like adherence, patient-doctor communication and cost-effectiveness.
Still, the potential impact of these tools, including the one whose testing Parks is leading, extends to society and the economy at large.
“Minority patients are not receiving treatment,” said Darrell Gaskin, a health economist and the director of the Center for Health Disparities Solutions at Johns Hopkins University in Baltimore. He helped develop the decisionmaking tool after Movement Is Life, a coalition that works to eliminate racial and ethnic disparities in joint health and which is involved in developing the tool, sought out his expertise.
“Even though we know in many cases that surgery will work and relieve pain and restore functionality and get people back to work quicker, they're not receiving surgery at the same rates as white patients are,” Gaskin said.
The information that the tool and the trial produce could also help sway insurers' thinking, Gaskin said. If payers start to recognize that they incur financial losses when a portion of their population suffers from knee pain but does not receive treatment, they might be more proactive about reaching out to these patients—and their doctors—so patients seek the most effective treatment.
The potential macroeconomic payoff from using such a tool and closing the yawning racial divides in healthcare are also vast. Research by Gaskin and others showed that that from 2003 through 2006, direct medical care expenditures and lost productivity due to racial health disparities are estimated to have cost the US more than $1.2 trillion.