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Home dialysis rates for end-stage kidney disease (ESKD) treatment are substantially lower in the US than in other high-income countries, yet there is limited knowledge on how to increase these rates.To report results from the first year of a nationwide randomized clinical trial that provides financial incentives to ESKD facilities and managing clinicians to increase home dialysis rates.Results were analyzed from the first year of the End-Stage Renal Disease Treatment Choice (ETC) model, a multiyear, mandatory-participation randomized clinical trial designed and implemented by the US Center for MedicareMedicaid Innovation. Data were reported on Medicare patients with ESKD 66 years or older who initiated treatment with dialysis in 2021, with data collection through December 31, 2021; the study included all eligible ESKD facilities and managing clinicians. Eligible hospital referral regions (HRRs) were randomly assigned to the ETC (91 HRRs) or a control group (211 HRRs).The ESKD facilities and managing clinicians received financial incentives for home dialysis use.The primary outcome was the percentage of patients with ESKD who received any home dialysis during the first 90 days of treatment. Secondary outcomes included other measures of home dialysis and patient volume and characteristics.Among the 302 HRRs eligible for randomization, 18 621 eligible patients initiated dialysis treatment during the study period (mean [SD] age, 74.8 [1.05] years; 7856 women [42.1%]; 10 765 men [57.9%]; 859 Asian [5.2%], 3280 [17.7%] Black, 730 [4.3%] Hispanic, 239 North American Native, and 12 394 managing clinicians. The mean (SD) share of patients with any home dialysis during the first 90 days was 20.6% (7.8%) in the control group and was 0.12 percentage points higher (95% CI, -1.42 to 1.65 percentage points; P = .88) in the ETC group, a statistically nonsignificant difference. None of the secondary outcomes differed significantly between groups.The trial results found that in the first year of the US Center for MedicareMedicaid Innovation-designed ETC model, HRRs assigned to the model did not have statistically significantly different rates in home dialysis compared with control HRRs. This raises questions about the efficacy of the financial incentives provided, although further evaluation is needed, as the size of these incentives will increase in subsequent years.ClinicalTrials.gov Identifier: NCT05005572.

Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors.Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method.Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P0.001), less likely to have private medical insurance (P0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]).Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.

Objective To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA). Methods Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method. Results Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]). Conclusion Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.

Although pregnancy in systemic lupus erythematosus (SLE) carries a high risk for mother and fetus, outcomes may be improving.To assess nationwide trends and disparities in maternal and fetal complications among pregnant women with SLE.Retrospective cohort study.United States, 1998 to 2015.Adult pregnant women with and without SLE who had hospitalizations recorded in the National Inpatient Sample (NIS) database.Outcome measures were in-hospital maternal mortality, fetal mortality, preeclampsia or eclampsia, caesarean sections, non-delivery-related admissions, and length of stay. To assess whether trends in outcomes over time differed between patients with SLE and those without SLE, logistic or linear regression with an interaction term between year and SLE (yes or no) was used. Nationwide population estimates incorporating sampling and poststratification weights were obtained.An estimated 93 820 pregnant women with SLE and 78 045 054 without SLE were hospitalized in the United States from 1998 through 2015. Outcomes improved during those 18 years. In-hospital maternal deaths (per 100 000 admissions) declined among patients with as well as those without SLE (442 vs. 13 for 1998 to 2000 and50 vs. 10 for 2013 to 2015), although the decrease was greater in women with SLE (difference in trends, P0.002). The percentage of patients with SLE in all pregnancy-related, as well as delivery-related, admissions increased significantly.The sample for this analysis was identified by using diagnostic codes; detailed information on hospital-specific trends, SLE disease activity, and medications was not available. Race trends could not be analyzed. Given that NIS uses weighted estimates, the incidence of outcomes reported may not be exact.In this large study examining SLE and non-SLE pregnancies over 18 years, in-hospital maternal mortality and overall outcomes improved markedly, particularly among women with SLE. However, improvement is still needed, because SLE pregnancy risks remain high.None.

Prescription opioid use (POU) is often a precursor to opioid use disorder (OUD) and subsequent consequences. Persons with chronic hepatitis C virus infection (CHC) may be at a higher risk of POU due to a higher comorbidity burden and social vulnerability factors. We sought to determine the burden of POU and associated risk factors among persons with CHC in the context of social vulnerability. We identified CHC persons and propensity-score matched HCV− controls in the electronically retrieved Cohort of HCV-Infected Veterans and determined the frequency of acute, episodic long-term and chronic long-term POU and the prevalence of social vulnerability factors among persons with POU. We used logistic regression analysis to determine factors associated with POU. Among 160,856 CHC and 160,856 propensity-score matched HCV-controls, acute POU was recorded in 38.4% and 38.0% (P = 0.01) respectively. Episodic long-term POU was recorded in 3.9% in each group (P = 0.5), while chronic long-term POU was recorded in 28.4% and 19.2% (P

Disparities by race/ethnicity and socioeconomic status (SES) exist in rehospitalization rates and inpatient mortality rates. Few studies have examined how length of stay (LOS, a measure of hospital efficiency/quality) differs by race/ethnicity and SES. This study's objective was to determine whether differences in risk-adjusted LOS exist by race/ethnicity and SES Using a retrospective cohort of 1,432,683 medical and surgical discharges, we compared risk-adjusted LOS, in days, by race/ ethnicity and SES (median household income by patient ZIP code in quartiles), using generalized linear models controlling for demographic and clinical factors, and differences between hospitals and between diagnoses. White patients were on average older than both Black and Hispanic patients, had more chronic conditions, and had a higher inpatient mortality risk. In adjusted analyses, Black patients had a significantly longer LOS than White patients (0.25-day difference when discharged to home and 0.23-day difference when discharged to non-home destinations, both P

Highlights • Autoimmune patients and rheumatologists face an unprecedented challenge during the COVID-19 pandemic and are changing medication practices in response. • About half of US rheumatologists believe COVID-19 risk may be heightened in rheumatic disease patients, regardless of their immunosuppressive medications. • There were significant differences in the management of biologics, steroids and NSAIDs in response to COVID-19 reported by rheumatologists in areas with a high case burden, compared to those in less affected areas., OBJECTIVE To investigate the perceptions and behaviors of rheumatologists in the United States (US) regarding the risk of COVID-19 for their autoimmune patients and the subsequent management of immunosuppressive and anti-inflammatory medications. METHODS We administered an online survey to a convenience sample of rheumatologists in the US from 4/8/20-5/4/20 via social media and group emails. Survey respondents provided demographic information such as, age, gender, state of practice, and practice type. We asked questions about COVID-19 risk in rheumatic patients, as well as their medication management during the pandemic. We conducted descriptive analysis and Multivariable regression models. RESULTS 271 respondents completed the survey nationally. 48% of respondents either agreed or strongly agreed with the statement “Patients with rheumatic diseases are at a higher risk of COVID-19 irrespective of their immunosuppressive medications”. 50% disagreed or strongly disagreed with the statement “The pandemic has led you to reduce the use/dosage/frequency of biologics”, while 56% agreed or strongly agreed with the statement “The pandemic has led you to reduce the use/dosage/frequency of steroids”. A third of respondents indicated that at least 10% of their patients had self-discontinued or reduced at least one immunosuppressive medication to mitigate their risk of COVID-19. Responses to these questions as well as to questions regarding NSAID prescription patterns were significantly different in the Northeast region of US compared to other regions. CONCLUSION In this national sample of rheumatologists, there are variations regarding perceptions of patients’ risk of COVID-19, and how to manage medications such as NSAIDs, biologics and steroids during the pandemic. These variations are more pronounced in geographical areas where COVID-19 disease burden was high.

This cohort study analyzes Medicare claims data to assess whether changes in joint replacement care are associated with Medicare’s Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients., Key Points Question How did joint replacement care change for White, Black, and Hispanic patients under Medicare’s Comprehensive Care for Joint Replacement (CJR) model? Findings In this cohort study of 688 346 patients receiving a joint replacement, CJR was associated with a reduction in readmissions for Black patients. Furthermore, whereas Black patients were previously more likely to be discharged to institutional postacute care than White patients, this gap narrowed under CJR. Meaning Among patients receiving joint replacements, the reduction in readmissions and decreased discharges to institutional postacute care among Black patients was a positive change under CJR, given concerns that value-based payment models may exacerbate disparities in care for racial/ethnic minorities., Importance There are marked racial/ethnic differences in hip and knee joint replacement care as well as concerns that value-based payments may exacerbate existing racial/ethnic disparities in care. Objective To examine changes in joint replacement care associated with Medicare’s Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients. Design, Setting, and Participants Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic patients undergoing joint replacement in 67 treatment (selected for CJR participation) and 103 control metropolitan statistical areas. Exposures The CJR model holds hospitals accountable for spending and quality of joint replacement care during care episodes (index hospitalization through 90 days after discharge). Main Outcomes and Measures The primary outcomes were spending, discharge to institutional postacute care, and readmission during care episodes. Results Among 688 346 patients, 442 163 (64.2%) were women, and 87 286 (12.7%) were 85 years or older. Under CJR, spending decreased by $439 for White patients (95% CI, −$718 to −$161; from pre-CJR spending in treatment metropolitan statistical areas of $25 264) but did not change for Black patients and Hispanic patients. Discharges to institutional postacute care decreased for all groups (−2.5 percentage points; 95% CI, −4.7 to −0.4, from pre-CJR risk of 46.2% for White patients; −6.0 percentage points; 95% CI, −9.8 to −2.2, from pre-CJR risk of 59.5% for Black patients; and −4.3 percentage points; 95% CI, −7.6 to −1.0, from pre-CJR risk of 54.3% for Hispanic patients). Readmission risk decreased for Black patients by 3.1 percentage points (95% CI, −5.9 to −0.4, from pre-CJR risk of 21.8%) and did not change for White patients and Hispanic patients. Under CJR, Black-White differences in discharges to institutional postacute care decreased by 3.4 percentage points (95% CI, −6.4 to −0.5, from the pre-CJR Black-White difference of 13.3 percentage points). No evidence was found demonstrating that Black-White differences changed for other outcomes or that Hispanic-White differences changed for any outcomes under CJR. Conclusions and Relevance In this cohort study of patients receiving joint replacements, CJR was associated with decreased readmissions for Black patients. Furthermore, Black patients experienced a greater decrease in discharges to institutional postacute care relative to White patients, representing relative improvements despite concerns that value-based payment models may exacerbate existing disparities. Nonetheless, differences between White and Black patients in joint replacement care still persisted even after these changes.

Objective This study was to examine the impact of the July 2011 Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh in pelvic organ prolapse (POP) repair by patients' race and ethnicity. Methods We conducted an observational cohort study of women undergoing POP repairs in 2008 to 2015 in New York State. We examined the changes in transvaginal mesh use in POP repairs before and after the FDA communication by patients' race and ethnicity. Piecewise logistic regression models were used to assess the trends of mesh use, adjusting for patient characteristics. We performed a subgroup analysis of the trends of transvaginal mesh use by racial groups, stratifying by patients' neighborhood socioeconomic status. Results We included 49,848 women (78% white, 7% black, and 15% Hispanic) with an average ± SD age of 60.2 ± 13.0 years. After the safety communication, the use of transvaginal mesh in POP repairs decreased among white women (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.41-0.50) and African Americans (OR, 0.48; 95% CI, 0.35-0.67) but remained stable among Hispanic women (OR, 0.88; 95% CI, 0.70-1.11). Only in the subgroup of patients from high-income areas, there was a trend toward decreasing mesh use among Hispanic patients after 2011 (OR, 0.71; 95% CI, 0.49-1.04). Conclusions The communications related to the safety of transvaginal mesh did not have an equal impact across racial groups. Mesh use decreased among white and African American women but not among Hispanic women after the 2011 FDA safety communication. Particular attention is warranted for patients from disadvantaged groups, especially low-income minorities, when disseminating medical device safety messages.

Key Points Question Is preoperative physical function associated with racial/ethnic disparities in functional outcomes after total knee arthroplasty among women? Findings In this cohort study of 10 325 women who underwent total knee arthroplasty, poorer preoperative physical function among black women was associated with poorer outcomes after total knee arthroplasty. Meaning Efforts to reduce disparities in functional outcomes after total knee arthroplasty should be focused preoperatively on optimizing the physical function of black women in the early stages of arthritis and reducing delays to surgical treatment once clinical need arises., Importance Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated. Objective To examine trajectories of PF by race/ethnicity before and after TKA among older women. Design, Setting, and Participants This cohort study was conducted among the prospective Women’s Health Initiative with linked Medicare claims data. A total of 10 325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017. Exposures Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively). Main Outcomes and Measures Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time. Results In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, −5.8 [95% CI, −8.0 to −3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, −7.8 [95% CI, −10.8 to −4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, −3.0 [95% CI, −5.3 to −0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods. Conclusions and Relevance This study suggests that black women had significantly poorer PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises., This cohort study uses data from the Women’s Health Initiative to examine trajectories of physical function by race/ethnicity before and after total knee arthroplasty among community-dwelling older women in the United States.

OBJECTIVE Perceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain. METHODS We analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self-reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and demographic variables. Cumulative disadvantage was defined as the number of socially disadvantaged groups to which each participant belonged (i.e., self-reported female sex, African American race, annual income of

Background Despite the importance of the hospital discharge destination field ("discharge code" hereafter) for research and payment reform, its accuracy is not well established. Objectives The aim of this study was to examine the accuracy of discharge codes in Medicare claims. Data sources 2012-2015 Medicare claims of knee and hip replacement patients. Research design We identified patients' discharge location in claims and compared it with the discharge code. We also used a mixed-effects logistic regression to examine the association of patient and hospital characteristics with discharge code accuracy. Results Approximately 9% of discharge codes were inaccurate. Long-term care hospital discharge codes had the lowest accuracy rate (41%), followed by acute care transfers (72%), inpatient rehabilitation facility (80%), and home discharges (83%). Most misclassifications occurred within 2 broad groups of postacute care settings: home-based and institutional care. The odds of inaccurate discharge codes were higher for Medicaid-enrolled patients and safety-net and low-volume hospitals. Conclusions Inaccurate hospital discharge coding may have introduced bias in studies relying on these codes (eg, evaluations of Medicare bundled payment models). Inaccuracy was more common among Medicaid-enrolled patients and safety-net and low-volume hospitals, suggesting more potential bias in existing study findings pertaining to these patients and hospitals.

Objective Rheumatoid arthritis (RA) is associated with adverse body composition profiles and low muscle density due to the accumulation of intramuscular fat. Linear regression was used to assess differences between RA patients and controls and to determine associations between muscle density, strength, and physical functioning. Methods Patients with RA, ages 18-70 years, and healthy control subjects underwent whole-body dual x-ray absorptiometry and peripheral quantitative computed tomography, in order to quantify the appendicular lean mass index (ALMI) and the fat mass index (FMI), visceral fat area, and muscle density. Dynamometry was used to measure hand grip strength and muscle strength at the knee and lower leg. Disability and physical functioning were measured using the Health Assessment Questionnaire (HAQ) and the Short Physical Performance Battery (SPPB). Linear regression analyses were performed to assess differences related to RA and associations between muscle density, strength, and function. Results The study group included 103 patients with RA (51 men) and 428 healthy control subjects. Among patients with RA, low muscle density was associated with higher disease activity, C-reactive protein and interleukin-6 levels, greater total and visceral fat area, lower ALMI Z scores, physical inactivity, and long-term use of glucocorticoids (>1 year). Patients with low ALMI Z scores had lower muscle density Z scores compared with reference participants with similarly low ALMI scores. Low muscle density was independently associated with lower muscle strength, higher HAQ scores, and lower SPPB scores, after adjustment for ALMI and FMI Z scores. Conclusion The low muscle density observed in patients with RA was associated with low muscle mass, excess adiposity, poor strength, and greater disability. Interventions to address poor muscle quality could potentially affect important functional outcomes.

Background Decision quality measures the degree to which care decisions are knowledge-based and value-aligned. Because military service emphasizes hierarchy, command, and mandates some healthcare decisions, military service may attenuate patient autonomy in healthcare decisions and lower decision quality. VA is the nation's largest provider of orthopedic care. We compared decision quality in a sample of VA and non-VA patients seeking care for knee osteoarthritis. Methods Our study sample consisted of patients newly referred to our orthopedic clinic for the management of knee osteoarthritis. None of the study patients were exposed to a knee osteoarthritis decision aid. Consenting patients were administered the Hip/Knee Decision Quality Instrument (HK-DQI). In addition, they were surveyed about decision-making preferences and demographics. We compared results to a non-VA cohort from our academic institution's arthroplasty database. Results The HK-DQI Knowledge Score was lower in the VA cohort (45%, SD = 22, n = 25) compared with the non-VA cohort (53%, SD = 21, n = 177) (p = 0.04). The Concordance Score was lower in the VA cohort (36%, SD = 49%) compared with the control cohort (70%, SD 46%) (p = 0.003). Non-VA patients were more likely to make a high-quality decision (p = 0.05). Non-VA patients were more likely to favor a shared decision-making process (p = 0.002). Conclusions Decision quality is lower in Veterans with knee osteoarthritis compared with civilians, placing them at risk for lower treatment satisfaction and possibly unwarranted surgical utilization. Our future work will examine if this difference is from conditioned military service behaviors or confounding demographic factors, and if conventional shared decision-making techniques will correct this deficiency.

Knee osteoarthritis is a painful, disabling condition that disproportionately affects African Americans. Existing arthritis treatments yield small to moderate improvements in pain and have not been effective at reducing racial disparities in the management of pain. The biopsychosocial model of pain and evidence from the positive psychology literature, suggest that increasing positive psychological skills (e.g., gratitude, kindness) could improve pain and functioning and reduce disparities in osteoarthritis pain management. Activities to cultivate positive psychological skills have been developed and validated; however, they have not been tested in patients with osteoarthritis, their effects on racial differences in health outcomes have not been examined, and evidence of their effects on health outcomes in patients with other chronic illnesses is of limited quality. In this article we describe the rationale and design of Staying Positive with Arthritis (SPA) study, a randomized controlled trial in which 180 African American and 180 White primary care patients with chronic pain from knee osteoarthritis will be randomized to a 6-week program of either positive skill-building activities or neutral control activities. The primary outcomes will be self-reported pain and functioning as measured by the WOMAC Osteoarthritis Index. We will assess these primary outcomes and potential, exploratory psychosocial mediating variables at an in-person baseline visit and by telephone at 1, 3, and 6 months following completion of the assigned program. If effective, the SPA program would be a novel, theoretically-informed psychosocial intervention to improve quality and equity of care in the management of chronic pain from osteoarthritis.

Objective.Rheumatoid arthritis (RA) is associated with muscle loss, osteoporosis, and fracture. We examined associations between skeletal muscle mass, strength, and quality and trabecular and cortical bone deficits in patients with RA and healthy controls.Methods.Participants, ages 18–75 years, completed whole-body dual-energy x-ray absorptiometry and peripheral quantitative computed tomography (pQCT) of the tibia to quantify appendicular lean mass and fat mass indices (ALMI, FMI), muscle density at the lower leg, trabecular bone density, and cortical bone thickness. Age-, sex-, and race-specific Z scores were calculated based on distributions in controls. Associations between body composition and pQCT bone outcomes were assessed in patients with RA and controls. Linear regression analyses assessed differences in bone outcomes after considering differences in body mass index (BMI) and body composition.Results.The sample consisted of 112 patients with RA (55 men) and 412 controls (194 men). Compared to controls, patients with RA had greater BMI Z score (p < 0.001), lower ALMI Z score after adjustment for FMI (p = 0.02), lower muscle strength Z score (p = 0.01), and lower muscle density Z score (p < 0.001). Among RA, ALMI Z scores were positively associated with trabecular density [β: 0.29 (0.062–0.52); p = 0.01] and cortical thickness [β: 0.33 (0.13–0.53; p = 0.002]. Associations were similar in controls. Bone outcomes were inferior in patients with RA after adjusting for BMI, but similar to controls when adjusting for body composition. Radiographic damage and higher adiponectin levels were independently associated with inferior bone outcomes.Conclusion.Patients with RA exhibit deficits in cortical bone structure and trabecular density at the tibia and a preserved functional muscle-bone unit. A loss of mechanical loading may contribute to bone deficits.

Objectives To develop and evaluate the psychometric properties of a new performance-based instrument (Physical and Cognitive Performance Test for Assisted Living Facilities (PCPT ALF)) designed to assess the physical and cognitive skills associated with performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Design There were three stages in this study: development of instrument items and validity testing, a feasibility pilot study, and a cross-sectional trial to establish construct and criterion validity and reliability. Setting One 116-bed assisted living facility (ALF). Participants After a pilot test with 10 residents, a cross-sectional trial was conducted with 55 additional residents. Measurements The Barthel Index and Functional Independence Measure were used to estimate criterion validity. Construct validity was examined using exploratory factor analyses (EFAs). Results Disattenuated correlations between the PCPT ALF and other tools were all greater than 0.72, supporting criterion validity. Internal consistency (physical ability, α = 0.95; cognitive support, α = 0.92) and 1-week test–retest reliability (PCPT ALF, P = .93) were high, as was interrater reliability (IRR) (physical ability, 0.99; cognitive support, 1.00). In two EFAs, a one-factor solution accounted for 64.1% of the variance for the physical ability subscale and 63.5% of the variance for the cognitive support subscale. Conclusion The findings provide early evidence of the PCPT ALF's validity and reliability. If confirmed, this study's findings may be used in future work to assess the success of interventions to prevent or slow decline in the skills associated with ADL and IADL performance in ALFs.

Few studies have examined comprehensively racial/ethnic variations in quality of end-of-life care. Examine end-of-life care quality received by Veterans and their families, comparing racial/ethnic minorities to nonminorities. This is a retrospective, cross-sectional analysis of chart review and survey data. Nearly all deaths in 145 Veterans Affairs Medical Centers nationally (n=94,697) in addition to Bereaved Family Survey (BFS) data (n=51,859) from October 2009 to September 2014. Outcomes included 15 BFS items and 4 indicators of high-quality end-of-life care, including receipt of a palliative care consult, chaplain visit, bereavement contact, and death in hospice/palliative care unit. Veteran race/ethnicity was measured via chart review and defined as non-Hispanic white, non-Hispanic black, Hispanic, or other. In adjusted models, no differences were observed by race/ethnicity in receipt of a palliative care consult or death in a hospice unit. Although black Veterans were less likely than white Veterans to receive a chaplain visit, Hispanic Veterans were more likely than white Veterans to receive a chaplain visit and to receive a bereavement contact. Less favorable outcomes for racial/ethnic minorities were noted on several BFS items. In comparison with family members of white Veterans, families of minority Veterans were less likely to report excellent overall care, and this difference was largest for black Veterans (48% vs. 62%). Bereaved family members of minority Veterans generally rate the quality of end-of-life care less favorably than those of white Veterans. Family perceptions are critical to the evaluation of equity and quality of end-of-life care.

Objectives To determine whether a novel measure of appendicular lean mass relative to fat mass is associated with physical functioning in RA. Methods In a cross-sectional design, three independent RA cohorts were retrospectively analysed. Whole-body DXA measures of appendicular lean mass index (ALMI, kg/m 2 ) and fat mass index (FMI, kg/m 2 ) were converted to age, sex and race-specific Z-scores using published National Health and Nutrition Examination Survey reference ranges. Adiposity-adjusted ALMI Z-scores (ALMI FMI ) were determined using a published method to adjust for normal associations between ALMI and FMI Z-scores. Associations between ALMI Z-scores, ALMI FMI Z-scores and physical functioning were assessed after adjusting for age, sex and study. Functional outcomes assessed included the HAQ, Valued Life Activities assessment and Short Physical Performance Battery. Low lean for age was defined as a Z-score of -1 or less. Results Our sample consisted of 442 patients with RA. The combined cohort had a mean ALMI Z-score of - 0.51 (1.08) and a mean ALMI FMI Z-score of - 0.58 (1.53), suggesting muscle mass deficits compared with a nationally representative sample. Greater ALMI FMI Z-scores demonstrated stronger associations with better functional outcomes compared with ALMI Z-scores. Associations were not attenuated with adjustment for systemic inflammation or pain. The FMI Z-score was independently associated with physical functioning, with a stronger association seen among patients with greater FMI Z-score. Adiposity-adjusted definitions of low lean mass more clearly identified those with functional impairment. Conclusion Estimates of appendicular lean mass that are adjusted for adiposity demonstrate stronger positive associations with functional outcomes compared with unadjusted estimates.

Objective Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders. Methods Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention. Results Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates. Conclusions Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

Total knee arthroplasty (TKA) is one of the most common elective procedures performed in adults with end-stage arthritis. Racial disparities in TKA outcomes have been described in the literature.To assess the association of race/ethnicity with discharge disposition and hospital readmission after elective primary TKA and to assess the association of nonhome discharge disposition with hospital readmission risk.This retrospective cohort study used data from the Pennsylvania Health Care Cost Containment Council Database, a large regional database that included demographic data from all discharges of patients who underwent elective primary TKA in 170 nongovernmental acute care hospitals in Pennsylvania from April 1, 2012, to September 30, 2015. Data analyses were conducted from September 29, 2017, to November 29, 2017.Patient race/ethnicity and discharge disposition.Discharge disposition and 90-day hospital readmission.Among 107 768 patients, 7287 (6.8%) were African American, 68 372 (63.4%) were women, 46 420 (43.1%) were younger than 65 years, and 60 636 (56.3%) were insured by Medicare. In multivariable logistic regression, among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) (adjusted relative risk ratio [aRRR], 2.49 [95% CI, 1.42-4.36]; P = .001) or a skilled nursing facility (SNF) (aRRR, 3.91 [95% CI, 2.17-7.06]; P .001) and had higher odds of 90-day hospital readmission (adjusted odds ratio [aOR], 1.30 [95% CI, 1.02-1.67]; P = .04). Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF (aRRR, 3.30 [95% CI, 1.81-6.02]; P .001). In both age groups, discharge to an IRF (age65 years: aOR, 3.62 [95% CI, 2.33-5.64]; P .001; age ≥65 years: aOR, 2.85 [95% CI, 2.25-3.61]; P .001) or SNF (age65 years: aOR, 1.91 [95% CI, 1.37-2.65]; P .001; age ≥65 years: aOR, 1.55 [95% CI, 1.27-1.89]; P .001) was associated with higher odds of 90-day readmission.This cohort study found that race/ethnicity was associated with higher odds of discharge to an IRF or SNF for postoperative care after primary TKA. Among patients younger than 65 years, African American patients were more likely than white patients to be readmitted to the hospital within 90 days. Discharge to an IRF or SNF for postoperative care and rehabilitation was also associated with a higher risk of readmission to an acute care hospital.

Objective Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. Methods We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. Results The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P Conclusions Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Objectives Adult Onset Still's Disease (AOSD) is a rare autoinflammatory disorder. There is relatively little known about the impact of social determinants of health on its outcomes. Our goal is to describe the racial/ethnic variations, morbidity and mortality of AOSD hospitalized patients in the US. Materials and Methods Adult US hospitalized patients between 2009–13 from a nationwide inpatient sample (NIS) database with AOSD were identified using ICD-9 code 714.2. NIS is the largest all-payer US inpatient database with approximately 8 million hospitalizations yearly. Patients with other autoimmune diseases were excluded. We used descriptive statistics to summarize patient and hospital characteristics. We performed survey-weighted logistic regression models adjusting for confounders to study our primary outcome: in-hospital mortality. Results Between 2009–13, 5,820 AOSD patients were hospitalized with a mean age of 53.6 (SE–0.61) years. 3817 (65.6%) were female, 56% white and 3% Asian. Macrophage Activating Syndrome (1.7%), Disseminated Intravascular Coagulation (DIC-1.1%) and Thrombotic Thrombocytopenic Purpura (0.4%), respectively, complicated the hospital course. There were 154 inpatient deaths in study period (mortality 2.6%). Mean age of patients who died in hospital was higher (62.4 years ± 3.1) and 13.9% were Asians. Patients of Asian origin had significantly higher odds of in-hospital death compared to whites (aOR = 6.39, 95% CI 1.77–23.1, p = 0.005). Mortality was significantly higher for patients whose hospital course was complicated by DIC (aOR = 29.69, 95% CI 5.5–160.41, p = 0.006). Conclusions In this national sample of patients hospitalized for AOSD, we found significant variations in In-hospital mortality.

Key Points Question Is the Medicare Comprehensive Care for Joint Replacement (CJR) model associated with the receipt of elective hip or knee replacement surgery in White, Black, and Hispanic beneficiaries? Findings In this cohort study of 49 595 269 beneficiary-year observations from 17 243 304 patients, the CJR model was associated with increases in the receipt of elective hip or knee replacement for Hispanic beneficiaries, decreases for Black beneficiaries, and no changes for White beneficiaries. Meaning In this study, the decrease in the receipt of hip or knee replacement among Black beneficiaries suggests a need for value-based payment models to be monitored for unintended consequences; the lack of similar findings among Hispanic beneficiaries may indicate that payment models have differential associations across racial/ethnic groups., Importance The Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear. Objective To examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries. Design, Setting, and Participants Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs). Exposures Starting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients’ hospitalization for hip or knee replacement and 90 days after the hospital discharge. Main Outcomes and Measures Beneficiary-level elective hip or knee replacement receipt in a given year. Results Among 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, −1.25 to −0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, −0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (−0.68, 95% CI, −1.20 to −0.15). Conclusions and Relevance In this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups., This cohort study examines the association of the Medicare Comprehensive Care for Joint Replacement model with the receipt of elective joint replacement across White, Black, and Hispanic Medicare beneficiaries.

This cohort study uses data from the National Cancer Database to examine whether the type of treatment facility is associated with overall survival among patients with a diagnosis of head and neck cancer., Key Points Question Is the type of treatment facility associated with overall survival in patients with head and neck cancer? Findings In this cohort study of 525 740 patients diagnosed with malignant neoplasms of the head and neck in the National Cancer Database from 2004 to 2016, treatment at academic comprehensive cancer programs, integrated network cancer programs, and comprehensive community cancer programs was associated with better overall survival rates than treatment at community cancer programs. Meaning This study’s findings suggest that improved understanding of socioeconomic differences and oncologic treatment disparities may improve clinical outcomes in head and neck cancer., Importance Patients with head and neck cancer receive care at academic comprehensive cancer programs (ACCPs), integrated network cancer programs (INCPs), comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). The type of treatment facility may be associated with overall survival. Objective To examine whether type of treatment facility is associated with overall survival after a diagnosis of head and neck cancer. Design, Setting, and Participants This population-based retrospective cohort study included patients from the National Cancer Database, a prospectively maintained, hospital-based cancer registry of patients treated at more than 1500 US hospitals. Participants were diagnosed with malignant tumors of the head and neck from January 1, 2004, through December 31, 2016. Data were analyzed from May 1 through November 30, 2019. Exposures Treatment at facilities classified as ACCPs, INCPs, CCCPs, or CCPs. Main Outcomes and Measures Overall survival after diagnosis and treatment of head and neck cancer was the primary outcome. The secondary outcome was the odds of receiving treatment at ACCPs and INCPs vs CCCPs and CCPs. Multivariable Cox proportional hazards regression and univariable and multivariable logistic regression models were used for analysis. Results A total of 525 740 patients (368 821 men [70.2%]; mean [SD] age, 63.3 [14.0] years) were diagnosed with malignant tumors of the head and neck during the study period. Among them, 36 595 patients (7.0%) were treated at CCPs; 174 658 (33.2%), at CCCPs; 232 867 (44.3%), at ACCPs; and 57 857 (11.0%), at INCPs. The median survival for patients with aerodigestive cancers was 69.2 (95% CI, 68.6-69.8) months; salivary gland cancers, 107.2 (95% CI, 103.9-110.2) months; and skin cancers, 113.2 (95% CI, 111.4-114.6) months. Improved overall survival was associated with treatment at ACCPs (hazard ratio [HR], 0.89; 95% CI, 0.88-0.91), INCPs (HR, 0.94; 95% CI, 0.92-0.96), and CCCPs (HR, 0.94; 95% CI, 0.92-0.95) compared with CCPs. Compared with patients with private insurance, those with government insurance (odds ratio [OR], 1.35; 95% CI, 1.29-1.41), no insurance (OR, 1.12; 95% CI, 1.09-1.16), or Medicaid (OR, 1.17; 95% CI, 1.14-1.20) were more likely to receive treatment at ACCPs and INCPs, whereas patients with Medicare were less likely to receive treatment at ACCPs and INCPs (OR, 0.95; 95% CI, 0.94-0.97). Compared with white patients, black (OR, 1.55; 95% CI, 1.52-1.59) and Asian (OR, 1.56; 95% CI, 1.49-1.63) patients were more likely to receive care at ACCPs and INCPs. Compared with patients from lower-income areas, patients from high-income areas were more likely to receive treatment at ACCPs and INCPs (OR, 1.25; 95% CI, 1.22-1.28). Conclusions and Relevance These findings suggest that treatment at ACCPs and INCPs was associated with a better overall survival rate in patients with head and neck cancer. Key social determinants of health such as race/ethnicity, socioeconomic status, and type of insurance were associated with receiving treatment at ACCPs and INCPs.

Given the rarity of parotid cancer, there is relatively few data published regarding outcomes. Utilizing the large sample population of the National Cancer Database (NCDB), we aim to examine the relationship between two key social determinants of health, demographics and socioeconomic status (SES), and parotid malignancy survival rates.Our analytic sample consists of patients with a diagnosis of primary malignancy of the parotid gland between 2004 and 2012 in the NCDB. We used univariable and multivariable Cox proportional hazard models to evaluate the relationship between overall survival rate and two key social determinants of health: demographics and SES.15,815 cases met inclusion criteria. Average age was 60.1 years and 8255 were male (52.2%). Median overall survival was 121 months with 5-year overall survival of 67.4%. Male sex and older age at diagnosis were associated with poorer overall survival (p 0.0001). We found that Asian Americans compared to whites had better overall survival (HR 0.75; 95% CI [0.58-0.95]). Black patients had improved survival compared to whites on univariate (HR 0.71; 95% CI [0.64-0.79]); but not multivariate analysis. Hispanic ethnicity and higher education level were protective (HR 0.76 95% CI [0.63-0.91] and HR 0.84 95% CI [0.74-0.96], respectively). We found no significant survival association based on income level.In this national sample of patients with parotid malignancy, a rare form of cancer, we found a significant correlation between important social determinants of health and overall survival rate. Females, Asian-Americans, Hispanics, and patients with higher education level have better overall survival.

Key Points Question Is positive psychology effective as a treatment for chronic arthritis pain and does it reduce race disparities in pain management? Findings In this randomized clinical trial involving 360 Veterans Affairs patients with chronic pain from osteoarthritis, a 6-week telephone-administered positive psychological intervention did not improve pain or functional difficulty vs a control program. No difference by race was found in the effect of the intervention. Meaning A telephone-administered positive psychological intervention was not associated with improvement in chronic pain or functional difficulty from osteoarthritis for either white or African American patients., Importance Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. Objective To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. Design, Setting, and Participants The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017. Interventions The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists. Main Outcomes and Measures The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction. Results The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P, This randomized clinical trial assesses the effects of a positive psychological intervention on pain and functional difficulty vs a control program in veterans with knee osteoarthritis and evaluates whether this management varies by race.

OBJECTIVE: Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA. METHODS: Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy (“How confident are you filling out medical forms by yourself?”), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics. RESULTS: In this sample (mean age 64.2 years, 23.6% women), 30.6% (n=110) reported taking opioid analgesics for OA, 54.2% (n=195) reported non-opioid use, and 15.3% (n=55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs. 10.5 vs. 11.9, p=0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs. 24.1% vs. 14.5%, p

Objective To investigate the prevalence and determinants of complementary and alternative medicine (CAM) interest level among a racially diverse cohort of inner city veterans who receive primary care at the VA Medical Center. Design Cross-sectional survey study Setting Philadelphia VA Medical Center Subjects Primary care patients (n = 258) Methods Interest in CAM was measured using a single item question. Patient treatment beliefs were assessed using validated instruments. We evaluated factors associated with patient interest in CAM using a multivariate logistic regression model. Results In this sample of 258 inner city primary care VA patients, interest in CAM was high 80% (n = 206). Interest in CAM was strongly associated with African American race [adjusted odds ratio (AOR) 2.19, 95% Confidence Interval (CI) 1.05–4.60, P = 0.037], higher levels of education (AOR 4.33, 95% CI 1.80–10.40, P = 0.001), presence of moderate to severe pain (AOR 2.02, 95% CI 1.02–4.78, P = 0.043), and expectations of benefit from CAM use (AOR 1.21, 95% CI 1.06–1.36, P = 0.004). Conclusions CAM approaches have broad appeal within this inner city cohort of veterans, particularly among African Americans, those that experience pain and those that expect greater benefit from CAM. These findings may inform the development of patient-centered integrative pain management for veterans.

Background Unintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence women's risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA women's disparate risk for unintended pregnancy. We sought to describe women's experiences with pregnancy-promoting behaviors by male partners and explore differences in such experiences by race. Methods Semistructured interviews were conducted with low-income, AA and White women aged 18 to 45 years recruited from reproductive health clinics in Western Pennsylvania to explore contextual factors that shape women's contraceptive behaviors. Narratives were analyzed using content analysis and the constant comparison method. Findings Among the 66 participants (36 AA and 30 White), 25 (38%) described experiences with male partner reproductive coercion. Narratives provided accounts of contraceptive sabotage, verbal pressure to promote pregnancy and specific pregnancy outcomes, and potential motives behind these behaviors. AA women in the sample reported experiences of reproductive coercion more often than White women (53% and 20%, respectively). AA women were also more likely than White women to attribute a current or prior pregnancy to reproductive coercion. AA women identified relationship transiency and impending incarceration as potential motivations for men to secure a connection with a female partner via pregnancy. Conclusions Our findings suggest that reproductive coercion may be a factor contributing to disparities in unintended pregnancy. More research, including population-level studies, is needed to determine the impact of reproductive coercion on unintended pregnancy and to understand the social and structural factors associated with pregnancy-promoting behaviors.

Objective.Low body mass index (BMI) is a risk factor for poor longterm outcomes in rheumatoid arthritis (RA). The purpose of this study was to identify factors associated with longterm changes in BMI.Methods.Subjects with RA from the Veterans Affairs (VA) Rheumatoid Arthritis (VARA) Registry (n = 1474) were studied. Information on inflammatory markers, presence of erosions, and smoking status were extracted from the VARA database. BMI was extracted from VA electronic medical records within 14 days of each visit date. VA pharmacy records were queried to identify prescriptions for specific RA therapies within 1 month of the visit date. We used robust generalized estimating equations marginal regression models to calculate independent associations between clinical variables and BMI over time. Similar models determined predictors of change in weight and risk of weight loss over the subsequent study observation period.Results.Increasing age, active smoking, and the presence of erosions at baseline were associated with lower BMI. Weight decreased over time among older adults. Factors associated with greater reductions in BMI over time and a greater risk of weight loss were higher inflammatory markers, smoking, older age, higher BMI, and less subsequent improvement in inflammation. Methotrexate use was associated with a lower risk of weight loss. The use of prednisone or anti-tumor necrosis factor therapies was not associated with change in BMI or the risk of weight loss independent of other factors.Conclusion.Greater age, greater inflammatory activity, and active smoking are associated with greater weight loss in RA over time.

Objective: To examine black-white and Hispanic-white differences in total knee arthroplasty from 2001 to 2013 in a large cohort of patients diagnosed with osteoarthritis in the Veterans Affairs (VA) Healthcare System. Methods: Data were from the VA Musculoskeletal Disorders Cohort, which includes data from electronic health records of over 5.4 million veterans with musculoskeletal disorders diagnoses. We included white (non-Hispanic), black (non-Hispanic), and Hispanic (any race) veterans age 50 years or older with an osteoarthritis diagnosis from 2001-2011 (N=539,841). Veterans were followed from their first osteoarthritis diagnosis until September 30, 2013. As a proxy for increased clinical severity, analyses were also conducted for a sub-sample restricted to those who saw an orthopedic or rheumatology specialist (N=148,844). We used Cox proportional hazards regression to examine racial and ethnic differences in total knee arthroplasty by year of osteoarthritis diagnosis, adjusting for age, sex, body mass index, physical and mental diagnoses, and pain intensity scores. Results: We identified 12,087 total knee arthroplasty procedures in a sample of 473,170 white, 50,172 black, and 16,499 Hispanic veterans. In adjusted models examining black-white and Hispanic-white differences by year of OA diagnosis, total knee arthroplasty rates were lower for black than for white veterans diagnosed in all but two years. There were no Hispanic-white differences regardless of when diagnosis occurred. These patterns held in the specialty clinic sub-sample. Conclusions: Black-white differences in total knee arthroplasty appear to be persistent in the VA, even after controlling for potential clinical confounders. This article is protected by copyright. All rights reserved.

Background Bystander cardiopulmonary resuscitation ( CPR ) is associated with increased survival from cardiac arrest, yet bystander CPR rates are low in many communities. The overall prevalence of CPR training in the United States and associated individual‐level disparities are unknown. We sought to measure the national prevalence of CPR training and hypothesized that older age and lower socioeconomic status would be independently associated with a lower likelihood of CPR training. Methods and Results We administered a cross‐sectional telephone survey to a nationally representative adult sample. We assessed the demographics of individuals trained in CPR within 2 years (currently trained) and those who had been trained in CPR at some point in time (ever trained). The association of CPR training and demographic variables were tested using survey weighted logistic regression. Between September 2015 and November 2015, 9022 individuals completed the survey; 18% reported being currently trained in CPR , and 65% reported training at some point previously. For each year of increased age, the likelihood of being currently CPR trained or ever trained decreased (currently trained: odds ratio, 0.98; 95% CI, 0.97–0.99; P OR , 0.99; 95% CI , 0.98–0.99; P =0.04). Furthermore, there was a greater then 4‐fold difference in odds of being currently CPR trained from the 30–39 to 70–79 year old age groups (95% CI , 0.10–0.23). Factors associated with a lower likelihood of CPR training were lesser educational attainment and lower household income ( P Conclusions A minority of respondents reported current training in CPR . Older age, lesser education, and lower income were associated with reduced likelihood of CPR training. These findings illustrate important gaps in US CPR education and suggest the need to develop tailored CPR training efforts to address this variability.

Purpose: What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care. Methods: Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012. Measurements and Main Results: Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects’ specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The “perfect handoff” was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs. Conclusions: A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.

Objective The C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) are important disease activity biomarkers in rheumatoid arthritis (RA). This study aimed to determine to what extent obesity biases these biomarkers. Methods Body mass index (BMI) associations with CRP level and ESR were assessed in 2 RA cohorts: the cross-sectional Body Composition (BC) cohort (n = 451), including whole-body dual x-ray absorptiometry measures of fat mass index; and the longitudinal Veterans Affairs Rheumatoid Arthritis (VARA) registry (n = 1,652), using multivariable models stratified by sex. For comparison, associations were evaluated in the general population using the National Health and Nutrition Examination Survey. Results Among women with RA and in the general population, greater BMI was associated with greater CRP levels, especially among women with severe obesity (P < 0.001 for BMI ≥35 kg/m2 versus 20–25 kg/m2). This association remained after adjustment for joint counts and patient global health scores (P < 0.001 in BC and P < 0.01 in VARA), but was attenuated after adjustment for fat mass index (P = 0.17). Positive associations between BMI and ESR in women were more modest. In men with RA, lower BMI was associated with higher CRP levels and ESR, contrasting with positive associations among men in the general population. Conclusion Obesity is associated with higher CRP levels and ESR in women with RA. This association is related to fat mass and not RA disease activity. Low BMI is associated with higher CRP levels in men with RA; this unexpected finding remains incompletely explained but likely is not a direct effect of adiposity.

A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA.We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA?Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report.The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679).A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future.Level I, therapeutic study.

Objective To examine the relationship between hospital procedure volume and surgical outcomes following elective primary total hip arthroplasty/total knee arthroplasty (THA/TKA). Methods Using the Pennsylvania Health Care Cost Containment Council database, we identified all patients who underwent elective primary THA/TKA in Pennsylvania. Hospitals were categorized according to the annual volume of THA/TKA procedures, as follows: ≤25, 26–100, 101–200, and >200. The 30-day complication rate and 30-day and 1-year mortality rates were assessed by logistic regression models, adjusted for age, sex, race, insurance type, hospital region, 3M All Patient Refined Diagnosis Related Group risk of mortality score, hospital teaching status, and bed count. Results In the THA and TKA cohorts, the mean age of the patients was 69 years, and 42.8% and 35%, respectively, were men. Compared with patients whose surgeries were performed at very-high-volume hospitals (>200 procedures/year), patients who underwent elective primary THA procedures at hospitals with a very low volume (≤25 procedures/year), a low volume (26–100 procedures/year), or a high volume (101–200 procedures/year) had higher multivariable-adjusted odds ratios (ORs) for venous thromboembolism (OR 2.0, 95% confidence interval [95% CI] 0.2–16.0), OR 3.4 [95% CI 1.4–8.0], and OR 1.1 [95% CI 0.3–3.7], respectively) and 1-year mortality (OR 2.1 [95% CI 1.2–3.6], OR 2.0 [95% CI 1.4–2.9], and OR 1.0 [95% CI 0.7–1.5], respectively). Among patients ages ≥65 years who underwent elective primary TKA at very-low-volume, low-volume, and high-volume hospitals, the ORs for 1-year mortality were significantly higher (OR 0.6 [95% CI 0.2–2.1], OR 1.6 [95% CI 1.0–2.4], and OR 0.9 [95% CI 0.6–1.3], respectively), compared with very-high-volume hospitals. Conclusion Performance of elective primary THA and TKA surgeries in low-volume hospitals was associated with a higher risk of venous thromboembolism and mortality. Confounding due to unmeasured variables is possible. Modifiable system-based factors/processes should be targeted to reduce the number of complications associated with THA/TKA procedures.

The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown.To examine association of past perceived discrimination with subsequent patient-provider communication.Observational cross-sectional study.African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities.Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes.Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [β=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (β=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (β=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results.Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

There are large and well-documented racial disparities in the use of total joint replacement (TJR) as a treatment for advanced knee and hip osteoarthritis.1-9 In particular, African American patients are significantly less likely than white patients to undergo knee or hip TJR.7, 10-12 Reasons for these disparities remain unclear, although research suggests they are not explained by differences in healthcare access or clinical need.8, 13-15 Patient preference may play a role, as studies have shown that African American patients are less willing than white patients to consider TJR as a treatment option for knee/hip osteoarthritis.16-19 What has not been well-studied as a contributing factor to racial disparities in TJR is the role of patient-provider communication regarding the management of knee/hip osteoarthritis in the orthopedic setting. Because osteoarthritis is progressive and incurable, the goals of treatment are to alleviate pain, improve function, and limit disability.20 Non-surgical treatments such as physical therapy or analgesic medications can be effective for moderate cases, but TJR is often the most appropriate and effective treatment for severe cases.21, 22 TJR is an elective and preference-sensitive procedure, however, as there are no established criteria indicating the need for TJR based on absolute levels of pain or disability. Patient-provider communication about osteoarthritis treatment options in the orthopedic setting is therefore likely to play a prominent role in the decision-making process about TJR. Examining whether racial differences occur in orthopedic discussions of osteoarthritis management is important given that racial variation in patient-provider communication has been documented in other healthcare settings. For instance, in primary care, visits with African American (vs. white) patients have been found to be more narrowly focused on biomedical issues23, less patient-centered, more dominated by physicians, and less positive (i.e., patients and physicians display less positive affect).24 Studies of patients with particular medical conditions (e.g., HIV25, lung cancer26, breast cancer27, depression28) have also found that African American patients tend to talk less than white patients in general or engage less in specific kinds of communication, such as rapport-building. Less research has examined racial differences in patient-provider communication in the orthopedic setting. In one analysis of orthopedic consultations among patients with a variety of conditions, Levinson and colleagues found that informational content of communication did not differ substantially by patient race, but visits with African American patients contained less relationship-building communication (i.e., responsiveness, respect, and listening) than visits with white patients.29 The current study examined whether there were racial differences in patient-provider communication in a sample of white and African American patients referred to orthopedic clinics specifically for the treatment of advanced knee or hip osteoarthritis. To provide a comprehensive analysis of communication, we coded patient-provider interactions using two methods. The Roter Interaction Analysis System (RIAS)30, 31 was used to examine the types of statements made by providers and patients (i.e., biomedical, psychosocial, rapport-building, or patient-activation), the provider-to-patient ratio of communication (i.e., physician verbal dominance), and the display of positive affect by patients and providers. The extent to which providers invited patients to participate in decision-making about treatment options was further assessed using the Informed Decision Making (IDM) Model.32, 33 IDM, which refers to thoughtful dialogue between a healthcare provider and a patient that leads to a clinical decision, exemplifies patient-centered care.32 IDM requires the discussion of technical aspects of a decision (e.g., nature of decision, alternatives, risks) as well as the assessment of patient understanding and preferences.32 We hypothesized that the previously discussed racial differences in patient-provider communication observed in other patient populations23-29 would be observed in our sample.

Background The extent to which racial/ethnic disparities in pneumonia care occur within or between hospitals is unclear. Objective Examine within and between-hospital racial/ethnic disparities in quality indicators and mortality for patients hospitalized for pneumonia. Research design Retrospective cohort study. Subjects A total of 1,183,753 non-Hispanic white, African American, and Hispanic adults hospitalized for pneumonia between January 2005 and June 2006. Measures Eight pneumonia care quality indicators and in-hospital mortality. Results Performance rates for the 8 quality indicators ranged from 99.4% (oxygenation assessment within 24 hours) to 60.2% (influenza vaccination). Overall hospital mortality was 4.1%. African American and Hispanic patients were less likely to receive pneumococcal and influenza vaccinations, smoking cessation counseling, and first dose of antibiotic within 4 hours than white patients at the same hospital (ORs = 0.65-0.95). Patients at hospitals with the racial composition of those attended by average African Americans and Hispanics were less likely to receive all indicators except blood culture within 24 hours than patients at hospitals with the racial composition of those attended by average whites. Hospital mortality was higher for African Americans (OR = 1.05; 95% CI = 1.02, 1.09) and lower for Hispanics (OR = 0.85; 95% CI = 0.81, 0.89) than for whites within the same hospital. Mortality for patients at hospitals with the racial composition of those attended by average African Americans (OR = 1.21; 95% CI = 1.18, 1.25) or Hispanics (OR = 1.18; 95% CI = 1.14, 1.23) was higher than for patients at hospitals with the racial composition of those attended by average whites. Conclusions Racial/ethnic disparities in pneumonia treatment and mortality are larger and more consistent between hospitals than within hospitals.

Objective To examine whether the observed difference in tubal sterilization rates between black and white women is dependent on racial/ethnic differences in vasectomy rates. Design Secondary analysis of national, cross-sectional survey. Setting 2002 National Survey of Family Growth. Patient(s) Women 15 to 44 years old with a current partner who were able to provide information about their partner's vasectomy status. Intervention(s) None. Main Outcome Measure(s) The primary outcome was tubal sterilization. Among women with a current partner who had not undergone vasectomy, a multivariable logistic regression model was used to estimate the effects of race/ethnicity on tubal sterilization after adjusting for potential confounders. Result(s) Of the 3,391 women in the sample, 14% of white women had a current partner who had undergone vasectomy compared with 5% of Hispanic women and 4% of black women. Among the 3,064 women whose partners had not undergone vasectomy, black women were more likely to undergo tubal sterilization (odds ratio: 1.6; 95% confidence interval: 1.1, 2.2) on the basis of adjusted multivariable analysis. Conclusion(s) After controlling for partner vasectomy status, black women were still more likely to undergo tubal sterilization than white women.

This study sought to examine the independent effect of patient race or ethnicity on the use of family planning services and on the likelihood of receiving counseling for sterilization and other birth control methods.This study used national, cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG). Our analysis included women aged 18-44 years who had heterosexual intercourse within the past 12 months, who were not actively seeking to get pregnant, and who had not undergone surgical sterilization. The primary outcome was receipt of family planning services within the past 12 months. Specific services we examined were (1) provision of or prescription for a method of birth control, (2) checkup related to using birth control, (3) counseling about sterilization, and (4) counseling about birth control.Although we found no racial/ethnic differences in the overall use of family planning services, there were racial/ethnic differences in the specific type of service received. Hispanic and black women were more likely than white women to receive counseling for birth control (adjusted OR 1.5, 95% confidence interval [CI] 1.2, 1.8, and adjusted OR 1.3, 95% CI 1.1, 1.7, respectively). Hispanic women were more likely than white women to report having been counseled about sterilization (adjusted OR 1.5, 95% CI 1.0, 2.3).Minority women were more likely to receive counseling about sterilization and other birth control methods. However, there were no differences in access to family planning services by race or ethnicity. Future studies are needed to examine the quality and content of contraceptive counseling received by minority compared with nonminority women.

Objectives. We sought to identify factors associated with appointment nonattendance for diagnostic testing of coronary artery disease among veterans. For patients with possible heart disease, appointment nonattendance may seriously compromise short- and long-term outcomes. Understanding factors associated with nonattendance may help improve care while reducing inefficiency in service delivery. Methods. We surveyed patients who attended (n = 240) or did not attend (n = 139) a scheduled cardiac appointment at a midwestern Veterans Administration medical center. Multivariable regression models were used to assess factors associated with nonattendance. Results. Younger age, lower income, unemployment, and longer wait times for appointments were predictive of nonattendance. Nonattenders reported fewer cardiac symptoms and were more likely to attribute their symptoms to something other than heart disease. Nonattendance was also associated with a coping style characterized by avoidance of aversive information. Logistical issues, fear of diagnostic procedures, disbelief that one had heart disease, and medical mistrust were some of the reasons given for missed appointments. Conclusions. Appointment nonattendance among veterans scheduled for cardiology evaluation was associated with several important cognitive factors. These factors should be considered when one is designing clinical systems to reduce patient nonattendance.

Objective To examine the independent effects of race/ethnicity and insurance status on desire for tubal sterilization reversal. Design Secondary analysis of cross-sectional data collected by the 2002 National Survey of Family Growth (NSFG). Setting Interviews were conducted in person by a trained female interviewer in the participant's home. Patient(s) The NSFG is designed to represent women and men 15–44 years of age in the U.S. household population. The sample consisted of 934 women who had undergone tubal sterilization at any time before being interviewed. Intervention(s) None. Main Outcome Measure(s) Desire for sterilization reversal. Result(s) Among women older than 30 years at time of surgery, black women were significantly more likely to desire sterilization reversal compared with white women (adjusted odds ratio, 2.6; 95% confidence interval, 1.2, 5.8). In the total cohort and in the subset of women 30 years or younger, there were no significant racial/ethnic variations in desire for sterilization reversal. Conclusion(s) Among women over age 30 at the time of tubal sterilization, black women were much more likely to express desire for reversal than white women.

Prior studies have indicated racial differences in patients' expectations for joint replacement surgery outcomes. The goal of this study was to measure these differences using a well-validated survey instrument and to determine if the differences could be explained by racial variation in disease severity, socioeconomic factors, literacy, or trust.Detailed demographic, clinical, psychological, and social data were collected from 909 male patients (450 African American, 459 white) ages 50-79 years with moderate or severe osteoarthritis (OA) of the hip or knee receiving primary care at 2 veterans affairs medical centers. The previously validated Joint Replacement Expectations Survey was used to assess expectations for pain relief, functional improvement, and psychological well-being after joint replacement.Among knee OA patients (n = 627), the unadjusted mean expectation score (scale 0-76) for African American patients was 48.7 versus 53.6 for white patients (mean difference 4.9, P0.001). For hip OA patients (n = 282), the unadjusted mean expectation score (scale 0-72) for African Americans was 45.4 versus 51.5 for whites (mean difference 6.1, P0.001). Multivariable adjustment for disease severity, socioeconomic factors, education, social support, literacy, and trust reduced these racial differences to 3.8 points (95% confidence interval [95% CI] 1.2, 6.3) among knee OA patients and 4.2 points (95% CI 0.4, 8.0) among hip patients.Among potential candidates for joint replacement, African American patients have significantly lower expectations for surgical outcomes than white patients. This difference is not entirely explained by racial differences in demographics, disease severity, education, income, social support, or trust.

Prior studies with limited clinical information reported a higher short-term mortality for men than for women with pulmonary embolism (PE). We compared 30-day mortality for men and women hospitalized with PE using a large statewide database.The sample consisted of 9304 female and 6227 male patient discharges for PE treated at 186 Pennsylvania hospitals between January 2000 and November 2002. We compared 30-day mortality for women and men, using random-effect logistic regression to adjust for clinical characteristics shown to predict early mortality, as well as patient race, insurance status, and hospital volume. We assessed interactions among sex, race, and clinical variables.The overall crude 30-day mortality rate was 8.9% for women and 9.8% for men. The unadjusted odds ratio (OR) of 30-day mortality for women was 0.90 (95% confidence interval [CI] 0.80, 1.00). After adjusting for baseline clinical and demographic characteristics, insurance status, and hospital volume, women had a lower risk of 30-day mortality (adjusted OR 0.8, 95% CI 0.7, 0.9).Women hospitalized with PE had significantly lower odds of 30-day mortality compared with men.

Objective To examine the independent effects of race or ethnicity and insurance status on use of tubal sterilization rates. Methods This study used cross-sectional data collected by the 2002 National Survey of Family Growth. The survey is designed to represent women and men aged 15-44 years in the household population of the United States. Our main outcome measure was tubal sterilization at any time before interview. A multivariable logistic regression model was used to estimate the effects of race or ethnicity and insurance status on rates of tubal sterilization after adjusting for important confounders. Results The sample consisted of 7,643 women: 66% were white, 15% were Hispanic, and 14% were African American; 68% had private insurance and 32% had public or no insurance. After adjusting for age, insurance status, parity, income, education, marital status, and religion, African-American women were more likely than white women to undergo tubal sterilization (adjusted odds ratio 1.43, 95% confidence interval 1.08-1.88). After adjusting for age, race or ethnicity, parity, income, education, marital status, and religion, women with public or no insurance were more likely to undergo sterilization compared with women with private insurance (adjusted odds ratio 1.38, 95% confidence interval 1.09-1.74). Conclusion African-American women and women with no or public insurance were more likely to have undergone tubal sterilization compared with white women and women with private insurance, respectively. Additional research to identify factors that influence women's decision to undergo sterilization is warranted. Level of evidence II.

Introduction Patient preferences contribute to marked racial disparities in the utilization of total knee replacement (TKR). The objectives of this study were to identify the determinants of knee osteoarthritis (OA) patients’ preferences regarding TKR by race and to identify the variables that may mediate racial differences in willingness to undergo TKR. Methods Five hundred fourteen White (WH) and 285 African-American (AA) patients with chronic knee pain and radiographic evidence of OA participated in the study. Participants were recruited from the community, an academic medical center, and a Veterans Affairs hospital. Structured interviews were conducted to collect socio-demographics, disease severity, socio-cultural determinants, and treatment preferences. Logistic regression was performed, stratified by race, to identify determinants of preferences. Clinical and socio-cultural factors were entered simultaneously into the models. Stepwise selection identified factors for inclusion in the final models (p

Objective Evaluate the relationship between patient preferences for total knee replacement (TKR) with receipt of TKR, and assess participant characteristics that may influence change in willingness to undergo TKR. Methods Structured interviews of knee osteoarthritis (OA) patients were conducted. Logistic regression models were conducted to assess the association between baseline willingness and eventual receipt of TKR, adjusted for sociodemographic and clinical variables. Mixed models for repeated measures were used to estimate the effects of sex, race, social support, Δ WOMAC, and orthopedic consult on change in willingness. Results A total of 589 participants were willing, and 215 participants were unwilling to undergo TKR. Willing participants, compared to others, were more often White (69.4% vs. 48.4%), with more than a high school education (60.8% vs. 47.0%) and employed (39.1% vs. 26.5%). At follow-up, the odds of having TKR were twice as high among those who were willing to have the procedure at baseline, but this was no longer significant when adjusted for demographic variables (adjusted OR=1.82, 95% CI: 0.89–3.69). Willingness to undergo TKR declined over 2 years. Among those who were willing to undergo TKR at baseline but did not obtain one, only 66.5% were still willing at the 2-year follow-up. This decline was less among those who had a greater increase (>median) in WOMAC disability (adjusted Δ = −0.34, 95% CI: −0.47 to −0.20) than those who had minimal change in their WOMAC disability ( p = 0.08). The decline in willingness was also less among those who had seen an orthopedic surgeon (adjusted Δ = −0.32, 95% CI: −0.46 to −0.17) than those who did not ( p = 0.05). Conclusions Preference for TKR was consistent with TKR surgery utilization, but not after controlling for patient demographic characteristics. Willingness to undergo TKR declined over time, but this decrease was mitigated by worsening OA-related disability and by consultation with an orthopedic surgeon.