JAAOS

JAAOS, Volume 15, No. suppl 1


Cobb Institute strategies for the elimination of health disparities.

The mission of the W. Montague Cobb/NMA Health Institute, which was founded in December 2004, is to study and provide solutions for the elimination of health disparities affecting African Americans as well as other underserved populations. The vision of the Cobb Institute is to become the repository of information regarding the health of African Americans, with holdings in statistics, solutions to health disparities, and best practices to prove the efficacy of these solutions. The major diseases on which the Cobb Institute is particularly focused include heart disease, diabetes, obesity, asthma, HIV/AIDS, and cancer (prostate, breast, colorectal). The scientific sections of the National Medical Association form the basis of the research capabilities of the Cobb Institute. Clinical trials performed by these research physicians and their institutions will provide cutting-edge data for the Cobb Institute to review, validate, and publicize in scientific journals and other communication vehicles.

    • Keywords:
    • Academies and Institutes|African Americans|Health Services Research|Health Status Disparities|Healthcare Disparities|Humans|Societies

    • Medical|United States|Vulnerable Populations

    • Subspecialty:
    • Clinical Practice Improvement

Cultural diversity, health care disparities, and cultural competency in American medicine.

A 2003 report by the Institute of Medicine identified several areas of disparity in health care due to discrimination (whether unintentional or intentional), bias, and prejudice. Given that most minority patients are treated by physicians from the majority group, the principles of cultural competency are extremely important. A health care provider is culturally competent when the patient is satisfied that a collaborative partnership has been established that facilitates successful and satisfactory delivery of care. To accomplish this, the physician makes an effort to overcome language barriers and learns to appreciate cultural differences. Taking the step to increase communication and awareness will enhance the quality of medical care delivered to minorities, leading to greater racial and ethnic harmony and understanding in the health care professions.

    • Keywords:
    • African Americans|Cultural Diversity|Delivery of Health Care|Health Services Accessibility|Hispanic Americans|Humans|Quality of Health Care|Religion|Social Class|United States

    • Subspecialty:
    • Clinical Practice Improvement

Culturally competent care education: overview and perspectives.

Health care disparities are a serious problem in the United States, for which an immediate and multifaceted response is required. A critical component in addressing these disparities is culturally competent care education. To that end, Harvard Medical School has established a Culturally Competent Care Education Committee, which drives key efforts in curriculum and faculty development. Although Harvard Medical School has substantial ongoing culturally competent care education practices, pedagogic methods for achieving the formidable objectives of culturally competent care education are not yet fully defined or developed. It is hoped that this report of current Harvard Medical School practices,perspectives, and experiences will help others institute or continue to develop culturally competent care education-related plans and activities. With time and study, the best and most efficient practices will emerge.

    • Keywords:
    • Cultural Diversity|Curriculum|Education

    • Medical

    • Undergraduate|Faculty

    • Medical|Humans|Licensure

    • Medical|Massachusetts|Minority Groups|New Jersey|Orthopedics|Schools

    • Medical|United States

    • Subspecialty:
    • Clinical Practice Improvement

Current activities in orthopaedic culturally competent care education.

Culturally competent care education, which involves educating physicians on being sensitive to the diverse characteristics and traits of each patient (eg, race, ethnicity, sex, faith background), is vital for the well-being of all patients. All medical disciplines are grappling with the best way to provide culturally competent care education. The Diversity Advisory Board of the American Academy of Orthopaedic Surgeons is charged with advancing diversity in the field of orthopaedic surgery. Diversity symposia were presented at the 2005 and 2006 Annual Meetings. In 2006, the AAOS developed the Cultural Competency Challenge CD-ROM, followed in 2007 by the Culturally Competent Care Guidebook, a companion to the CD-ROM. Culturally competent care legislation has been enacted in California and New Jersey, and legislation is pending in Arizona, Illinois, New York, and Texas, making these resources even more timely. To best care for all patients, each physician must be aware of his or her own identity and be sensitive to the unique realities of each patient with whom the physician comes into contact.

    • Keywords:
    • African Americans|Arabs|Asian Americans|Cultural Competency|Cultural Diversity|Delivery of Health Care|Education

    • Medical

    • Graduate|Hispanic Americans|Humans|Islam|Minority Groups|Orthopedics|Physician-Patient Relations|United States

    • Subspecialty:
    • Clinical Practice Improvement

Disparities in orthopaedic surgical intervention.

Race- and ethnicity-based health disparities have been identified both in health care generally and in orthopaedics specifically. Despite this body of research, it remains unclear why these disparities exist. Research has been done on disparities in patients with cardiovascular disease and diabetes, as well as in patients who are candidates for hip or knee arthroplasty. With regard to disparities in orthopaedics, differences in the rates of total hip and knee replacement surgery have been studied the most extensively. To better understand health disparities in orthopaedics and in health care as a whole, patient-, provider-, and health care-related factors must be examined more fully.

    • Keywords:
    • African Americans|Amputation|Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Cultural Diversity|Diabetic Angiopathies|Hispanic Americans|Humans|United States|United States Department of Veterans Affairs

    • Subspecialty:
    • Clinical Practice Improvement

Ethnic and racial disparities in diagnosis, treatment, and follow-up care.

Studies from four areas of musculoskeletal health care disparities were reviewed to determine the root causes of the disparities and gain insight into measurable interventions. The areas of musculoskeletal health were total joint arthroplasty, amputation for patients with diabetes, rehabilitation of and impairment in patients with stroke, and morbidity associated with unintentional injuries. The Jenkins Model on Health Disparities was used to investigate and rank the contributing causes (socioeconomic status, sociocultural beliefs, racism, biology) of the health care disparities. No single root cause was found for any of the conditions. Thus, all contributing factors must be considered when planning meaningful interventions.

    • Keywords:
    • African Americans|Amputation|Arthroplasty

    • Replacement|Culture|Diabetic Angiopathies|Humans|Minority Groups|Rehabilitation|Socioeconomic Factors|Stroke|United States|Wounds and Injuries

    • Subspecialty:
    • Clinical Practice Improvement

From earth to Mars: sex differences and their implications for musculoskeletal health.

Historically, most diagnostic and treatment modalities have been based on a male model. Osteoporosis is one of the few diseases in which there has been sex-based research and treatment bias in favor of women. As such, it is not known whether treatments developed for women will be efficacious for men. Similarly, scientists are just beginning to research whether sex-based differences in musculoskeletal health exist with extended space travel. Both women and men lose muscle and bone with extended space travel, but the low numbers of female astronauts combined with a lack of discrete data make it challenging to accurately pinpoint sex-based differences. More data collection is needed to ensure that the musculoskeletal health of astronauts is better managed both on earth and in space.

    • Keywords:
    • Aerospace Medicine|Female|Humans|Male|Musculoskeletal Physiological Phenomena|Research|Sex Characteristics|Weightlessness

    • Subspecialty:
    • General Orthopaedics

    • Basic Science

Genetic and social environment interactions and their impact on health policy.

Genetic and social factors are not as separate as once thought. Researchers within the social sciences are beginning to realize that genetics and the social environment interact synergistically to affect health behaviors and outcomes. This way of thinking is leading to new research models and is influencing the development of research initiatives. The importance of this gene-social environment paradigm is evident in current and proposed health policies, and future research likely will spur further questions related to various areas of public policy.

    • Keywords:
    • Health Behavior|Health Policy|Health Services Research|Humans|Models

    • Theoretical|Outcome Assessment (Health Care)|Pharmacogenetics|Social Environment|United States

    • Subspecialty:
    • General Orthopaedics

Improving diversity in orthopaedic residency programs.

Achieving a balanced diversity in orthopaedic residency programs is a critical component in improving the quality of orthopaedic care delivered to all patients. Compared with the demographics of medical school classes, women are notably underrepresented in orthopaedic residency programs, and racial and ethnic minority groups are unevenly represented. Diversifying residency programs positively affects all residents and their ability to deliver care and create positive physician-patient relationships.

    • Keywords:
    • Adult|Cultural Diversity|Female|Humans|Internship and Residency|Minority Groups|Orthopedics|Physicians

    • Women|United States

    • Subspecialty:
    • Clinical Practice Improvement

Perspectives on health disparities in orthopaedic oncology.

A few studies indicate that race- and culture-related differences exist among patients with bone tumors. However, there is little information regarding sarcomas. Existing studies indicate that, in the United States, race and cultural background may not significantly affect the survival rate of patients with sarcoma. As we learn more, however, orthopaedic oncologists should look to areas of oncology in which race-based disparity has been reported-specifically, among patients with prostate or breast cancer. These patient populations have been more widely studied, and physicians have pinpointed measures to reduce or eliminate gaps in patient care and prognosis. In particular, oncologists have called for culture-specific patient education. Further research is required to identify disparities, if any, and to ensure equitable patient prognoses.

    • Keywords:
    • African Americans|Bone Neoplasms|Culture|Hispanic Americans|Humans|Minority Groups|Neoplasms|Sarcoma|United States

    • Subspecialty:
    • Musculoskeletal Oncology

    • Clinical Practice Improvement

Racial and ethnic differences in osteoporosis.

Osteoporosis is a significant public health issue in the United States. This common and costly disease is a major cause of disability in elderly women. Although advances have been made in awareness, prevention, diagnosis, and treatment, osteoporosis remains a silent and underdiagnosed disease for many women. However, osteoporosis is particularly underdiagnosed in women in racial and ethnic minority groups in the United States. Even though the opportunity for prevention is great, disparities in incidence, awareness, diagnosis, treatment, and outcomes exist across racial and ethnic lines.

    • Keywords:
    • African Americans|Body Mass Index|Bone Density|Female|Hip Fractures|Hispanic Americans|Humans|Male|Minority Groups|Osteoporosis|Risk Factors|United States

    • Subspecialty:
    • Clinical Practice Improvement

Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System.

Elective total joint arthroplasty is an effective treatment option for end-stage osteoarthritis of the hip and knee. The demand for arthroplasty is anticipated to increase as the proportion of older patients with hip and knee osteoarthritis continues to rise in the United States and worldwide. Studies have documented marked racial and ethnic differences in the utilization rates of hip and knee arthroplasty in the United States. The reasons for these differences are complex and include patient-level factors, such as treatment preference; provider-level factors, such as physician-patient communication style; and system-level factors, such as access to specialist care. Most of the studies on racial and ethnic disparities in joint arthroplasty utilization have been based on data from the Medicare database. However, Veterans Administration-based studies have recently confirmed these findings and have indicated potential patient-level factors, such as patient perception of and familiarity with joint arthroplasty, that may play a role in this disparity.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Health Services Research|Humans|Knee Prosthesis|Minority Groups|Osteoarthritis|Outcome Assessment (Health Care)|Prosthesis-Related Infections|Risk Factors|United States|United States Department of Veterans Affairs

    • Subspecialty:
    • Clinical Practice Improvement

Sex differences in osteoarthritis of the hip and knee.

The prevalence, incidence, and severity of osteoarthritis are different in women than in men. Women are more likely than men to suffer from osteoarthritis,and women experience more severe arthritis in the knee. Genetics, anatomy,and prior knee injury are risk factors for developing osteoarthritis. Although the presentation of osteoarthritis does not differ between men and women,symptom severity does. Additionally, women are three times less likely than men to undergo hip or knee arthroplasty. Patient education, particularly for women, must be improved so that women with osteoarthritis who are candidates for hip and knee arthroplasty not only receive treatment but also receive it in a timely manner.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Female|Humans|Male|Osteoarthritis

    • Hip|Osteoarthritis

    • Knee|Osteoporosis|Sex Factors

    • Subspecialty:
    • Adult Reconstruction

The female knee: anatomic variations.

Traditional knee implants have been designed "down the middle,"based on the combined average size and shape of male and female knee anatomy.Sex-based research in the field of orthopaedics has led to new understanding of the anatomic differences between the sexes and the associated implications for women undergoing total knee arthroplasty. Through the use of a comprehensive bone morphology atlas that utilizes novel three-dimensional computed tomography analysis technology, significant anatomic differences have been documented in the shape and size of female knees compared with male knees. This research identifies three notable anatomic differences in the female population: a less prominent anterior condyle, an increased Q angle, and a reduced medial-lateral:anterior-posterior aspect ratio.

      • Subspecialty:
      • Sports Medicine

      • Basic Science

    The role of genetic and sociopolitical definitions of race in clinical trials.

    Although the concept of race has been disputed for decades, race continues to be used as a variable in biomedical research. Public Law 103-43 calls on the National Institutes of Health to develop guidelines for defining "minority group" and "their subpopulations" for the purposes of ensuring that they are included in clinical trials. Current guidelines use census racial categories, even though these categories are labeled as not scientific by their creator, the Office of Management and Budget. Three policy options exist for improving the National Institutes of Health Policy on Reporting Race and Ethnicity: (1) using genetic ancestry instead of census racial categories;(2) developing a standardized definition of race using current science; and(3) redefining minority group populations and subpopulations using social environment variables rather than census racial categories.

      • Keywords:
      • Clinical Trials as Topic|Continental Population Groups|Guidelines as Topic|Human Genome Project|Humans|Minority Groups|Terminology as Topic|United States

      • Subspecialty:
      • Clinical Practice Improvement

    The role of the department chair in promoting diversity.

    The department chair has a broad sphere of influence in which to promote diversity. The most immediate sphere of influence is on the department physicians(faculty, residents, and fellows) as well as administrators and support staff. The chair also can potentially influence this same group of individuals throughout the medical school as well as throughout the hospital. In addition, the chair can be extremely influential in her or his interactions with the community. Effectively promoting diversity can be accomplished by terminating the employment of individuals who discourage or minimize diversity, educating those who ignore diversity, and cultivating and encouraging constituents who value and manage diversity. If our goal as orthopaedic surgeons is to provide the most effective care to our diverse patient base, we must expand our level of care beyond the "three A's" that have for so long determined clinical success-affability, availability, and ability-to the "four A's:"affability, availability, ability, and awareness.

      • Keywords:
      • Academic Medical Centers|Cultural Competency|Cultural Diversity|Humans|Organizational Objectives|Orthopedics|Physician Executives|Professional Role|Social Values|Texas

      • Subspecialty:
      • Clinical Practice Improvement

    Utilization of joint arthroplasty: racial and ethnic disparities in the Veterans Affairs Health Care System.

    Studies within the Veterans Administration health care system have been very useful in identifying the existence of racial and ethnic disparities with regard to patient utilization of hip and knee joint arthroplasty. Existing studies have focused on three factors: estimates of joint arthroplasty utilization,postoperative outcomes, and patient-related variables (eg, expectations of and familiarity with the procedure, religious beliefs). Although Veterans Administration-based studies have produced helpful data, these data are limited because the populations studied are not representative of the larger US population. Specifically, studies from the Veterans Administration health care system are composed of a predominantly male patient demographic;in addition, patients are more likely to have lower income and education levels than the US population as a whole.

      • Keywords:
      • Arthroplasty

      • Replacement|Arthroplasty

      • Replacement

      • Hip|Arthroplasty

      • Knee|Female|Healthcare Disparities|Hospitalization|Hospitals

      • Veterans|Humans|Male|Minority Groups|Outcome Assessment (Health Care)|Quality of Life|United States|United States Department of Veterans Affairs

      • Subspecialty:
      • Clinical Practice Improvement

    Why winners win: decision making in medical malpractice cases.

    A high percentage of physicians will, at some time in their careers, face a lawsuit, possibly finding themselves in the courtroom even when they have not made a medical mistake. Despite the presumption that juries are biased in favor of injured plaintiffs, physicians win most of their trials. Why this occurs and how juries make their decisions are topics of ongoing interest. Research has been done on jury decision making, including what, if any, the roles of race and sex play in the process. It is essential that those who enter the courtroom understand both the power they have to influence the outcome of their own trials and why it is that issues of character continue to be so important to juries.

      • Keywords:
      • Clinical Competence|Decision Making|Expert Testimony|Humans|Malpractice|United States

      • Subspecialty:
      • Clinical Practice Improvement

    Women and minorities in orthopaedic residency programs.

    Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs because of lack of interest, lack of appropriate mentoring and role models, or other factors.

      • Keywords:
      • Adult|Cultural Diversity|Female|Humans|Internship and Residency|Male|Minority Groups|Orthopedics|Physicians

      • Women|United States

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