Clinical appropriateness and not race predicted referral for joint arthroplasty




To understand the reasons behind racial disparities in the use of total joint arthroplasty (TJA), we sought to examine the predictors of time to referral to orthopedic surgery for consideration of joint replacement.


In this prospective, longitudinal study of 676 primary care clinic patients with at least a moderately severe degree of hip or knee osteoarthritis (OA), we examined the effects of race, health beliefs (i.e., perceived benefits and risks) of TJA, and clinical appropriateness of TJA on referral to orthopedic surgery.


The sample included 255 African Americans (38%) and 421 whites (62%); 523 patients had knee OA (78%) and 153 had hip OA (22%). Subjects were 60% male, with a mean ± SD age of 64 ± 9 years, a mean ± SD body mass index of 33.6 ± 8 kg/m2, and a mean ± SD summary Western Ontario and McMaster Universities Osteoarthritis Index score of 56 ± 14, suggesting moderately severe OA. At baseline, African Americans perceived fewer benefits and greater risk from TJA than whites. There were no significant racial group differences in the proportions of cases deemed clinically appropriate for TJA. After controlling for potential confounders, clinical appropriateness (hazard ratio [HR] 1.95, 95% confidence interval [95% CI] 1.15–3.32; P = 0.01) predicted referral to orthopedic surgery. Neither race (HR 1.30, 95% CI 0.94–2.05; P = 0.1) nor health beliefs (HR 1.0, P = 0.5) were associated with referral status.


In this sample of primary care clinic patients, African Americans and whites were equally likely to be referred by their physicians to orthopedic surgery. Clinical appropriateness predicted future referral to orthopedic surgery, and not race or TJA-specific health beliefs.