Educational Intervention for Knee Pain

The proposed project represents the next phase in a trajectory of VA research designed to
eliminate racial disparities in the utilization of knee joint replacement - an effective
treatment option for end-stage knee osteoarthritis (OA). Numerous studies have documented the
existence of marked racial disparities in the utilization of knee joint replacement in OA.
African-Americans (AA) are two to five times less likely than white patients to receive knee
joint replacement for lower extremity OA. Our prior work has shown that compared to white
patients, AA patients expect worse outcomes from this treatment and, consequently, are less
willing to consider joint replacement even when clinically indicated and recommended by a
physician. Patient willingness, an attitudinal disposition modifiable with education and
counseling, has emerged as a key patient-level mediator in the utilization of elective
medical procedures, such as knee joint replacement.

The short-term goals of this randomized, controlled trial are to demonstrate the efficacy of
interventions to improve understanding of knee joint replacement risks, benefits, and
expected outcomes among AA primary care patients, increase willingness to consider knee joint
replacement among AA primary care patients, and increase primary care referral rates for
surgical consideration for AA patients who meet the indications for knee joint replacement.
We will test a multi-faceted intervention consisting of a knee OA decision aid video
developed by the Foundation for Informed Medical Decision Making alone or in combination with
individually tailored patient counseling using Motivational Interviewing versus an attention
control. The long-term objective is to reduce or eliminate the racial gap in the utilization
of knee joint replacement. The central hypothesis of this proposal is that the scientifically
accurate, high quality patient-centered information on knee arthritis and joint replacement
provided by the knee OA decision aid, alone or in combination with motivational interviewing,
will improve patient understanding of knee joint replacement outcomes, increase patient
willingness to consider knee joint replacement, and consequently lead to higher rates of
referral for surgical consideration when clinically indicated. With increased referral rates,
currently a major bottleneck in the path to joint replacement, more AA patients will receive
recommendations for surgery, thus potentially reducing racial differences in the utilization
of this procedure. This proposal is innovative because it is the first patient-centered
evidence-based VA intervention trial to use a decision aid alone or in combination with
motivational interviewing to intervene on a well-documented and marked racial disparity in
joint replacement that exists within and outside the VA health care system.

Primary Specific Aims:

1. To examine the effectiveness of the proposed intervention strategies (DA alone, MI alone
or a combined DA+MI)) to improve willingness to consider knee joint replacement when
clinically indicated among AA primary care patients.

2. To examine the effectiveness of the proposed intervention strategies on patient
expectations of knee joint replacement risks/benefits among AA primary care patients.

3. To examine the effectiveness of the proposed intervention strategies in increasing
primary care referrals for surgical evaluation of AA patients with knee OA.

Secondary Specific Aim: To examine the effectiveness of the proposed intervention strategies
to increase AA patient likelihood of receiving knee joint replacement within 12 months of the
intervention.

A randomized, controlled factorial design will be utilized to examine the effectiveness of
knee OA decision aid and/or MI compared with attention control on select key patient-centered
and process of care outcomes. We will recruit approximately 600 AA primary care patients (150
at the VAPHS, 150 at the LSCDVAMC, and 300 at the PVAMC) who meet the American College of
Rheumatology clinical indications for knee joint replacement and randomize them into either
intervention arms or attention control. We will assess patient expectations, willingness and
referral to joint replacement. We will also collect qualitative data on doctor-patient
communication following the intervention or control so that we can assess (in the future)
whether or not the interventions impact study outcomes through improved quality of
communication. This study will provide hard evidence needed to improve quality of care for
African-American VA patients who have end-stage knee OA, a major cause of disability and
functional decline in VA elderly patients.

Inclusion Criteria:

VA Pittsburgh Healthcare System, Philadelphia VA Medical Center, Louis Stokes Cleveland
VAMC, AA primary care patients > age 50 who meet clinical criteria for knee OA (i.e.,
chronic, frequent knee pain based on the NHANES questions, WOMAC score = 39, and
radiographic evidence of knee OA with K-L grade =2) are eligible for enrollment

Exclusion Criteria:

- Patients who have prior history of any:

- major joint replacement

- terminal illness (e.g., end-stage cancer)

- physician-diagnosed inflammatory arthritis (i.e., rheumatoid arthritis,
connective tissue disease, ankylosing spondylitis or other seronegative
spondyloarthropathy)

- contra-indications to replacement surgery (e.g., lower extremity paralysis as
result of stroke)

- Patients who are not willing to be randomized

- Do not have the presence of knee OA

- Do not have telephone service